NEW PATIENT INFORMATION FORM
It is very important you fill out all of the fields to the best of your ability. We may ask you to provide the same information more than once. This is very helpful. We apologize for any inconvenience.
Name
*
First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
Date
Sex
*
Male
Female
Marital Status
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Best Contact Phone Number
*
-
Area Code
Phone Number
Home Phone (If different than best contact phone number)
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Area Code
Phone Number
Cell Phone Number (If different than best contact phone number)
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Area Code
Phone Number
Work Phone Number
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Area Code
Phone Number
EMERGENCY CONTACT INFORMATION
Emergency Contact
*
First Name
Last Name
Emergency Contact Best Contact Phone Number
*
-
Area Code
Phone Number
INSURANCE INFORMATION
Primary Insurance (Commercial / State / Federal Insurance Company / Carrier) (*Skip this if you have Workers Compensation or No Fault* You will be asked for information regarding Workers Compensation or No Fault at a later point.)
(Ex. MVP, Empire BCBS, Aetna, Medicare, Medicaid etc.)
Primary Insurance Policy Holder
First Name
Last Name
Date of Birth of Primary Insurance Policy Holder
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Month
-
Day
Year
Date
Effective Date of Primary Insurance
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Month
-
Day
Year
Date
Policy Number of Primary Insurance
Group Number of Primary Insurance
Secondary Insurance (Commerical / State / Federal)
(Ex. MVP, Empire BCBS, UHC, AARP, Medicaid etc.)
Policy Number of Secondary Insurance
Group Number of Secondary Insurance
PHARMACY INFORMATION
Pharmacy Name and Location (Ex. Drug Store - Rt 9, Poughkeepsie)
PRIMARY CARE PHYSICIAN INFORMATION
Primary Care Physician
First Name
Last Name
Primary Care Physician Phone Number
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Area Code
Phone Number
Primary Care Physician Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
REFERRING PHYSICIAN INFORMATION
Referring Physician Name
First Name
Last Name
Referring Physician Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referring Physician Specialty
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WORKERS COMPENSATION and/or NO FAULT INFORMATION
Workers Compensation / No Fault Carrier
WC / NF - Date of Injury
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Month
-
Day
Year
Date
WC / NF Body Part(s) Covered
WC / NF - Adjuster/Representative Name
WC / NF - Adjuster/ Representative Phone Number
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Area Code
Phone Number
WC / NF - Carrier Claim Number
WC (Only) - WCB Number
WC / NF - Claim Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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CLINICAL INFORMATION
It is very important you fill out all of the following fields to the best of your ability. We may ask you to provide the same information more than once. This is very helpful. We apologize for any inconvenience this may cause and we thank you for taking the time to complete this form.
Please draw on the picture below and indicate where you're having the pain
*
Your Name
*
First Name
Last Name
Referred By
First Name
Last Name
Your Height (ft, inches)
*
Your Weight (lbs)
*
Age
*
Sex
*
Male
Female
Approximately how long ago did your pain begin?
*
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Day
-
Month
Year
Date
Describe event(s) related to the start of your pain
*
Please describe the location of the pain
*
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DESCRIPTION OF PAIN
How would you describe this pain?
*
Throbbing
Shooting
Sharp
Cramping
Hot-burning
Aching
Heavy
Tender
Splitting
Tiring-Exhausting
Sickening
Fearful
Punishing-cruel
None
Please check additional symptoms you may be experiencing
*
Tingling (pins-needles)
Pain EVEN with bed-rest
Cold / Hot skin
Changes in skin color
Chills / Night Sweats
Sensitive areas to touch
Repeated infections
Uncontrolled loss of bowel
Uncontrolled loss of urine
Weight loss (10-15 pounds in 2 weeks or less)
Weakness
Numbness
Imbalance
Swelling
Fever
Cramps
Difficulty in Walking
I do not have any of these symptoms
How often do you have your pain?
*
Constantly (80-100% of time)
Frequently (50-80% of the time)
Intermittently (25-50% of the time)
Occasionally (less than 25% of the time)
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AVERAGE DAILY PAIN
YOUR AVERAGE daily pain
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YOUR WORST daily pain
*
YOUR LEAST daily pain
*
HOW DO THE FOLLOWING AFFECT YOUR PAIN?
*
Increases my Pain
Reduces my Pain
N/A
Standing
Sitting
Lying Down
Walking
Exercise / Moving the Affected Part
Relaxation
Coughing or Sneezing
Urination or Bowel Movement
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INDICATE THE LEVEL OF RELIEF FROM EACH ACTIVITY
Type a question
*
Excellent Relief
Moderate Relief
No Relief
N/A
Bed Rest
Exercise
Heat or Ice
Physical Therapy
Traction
TENS Machine
Chiropractor
Acupuncture
Relaxation Techniques
Nerve Blocks or Injections
Surgery
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DIFFICULT ACTIVITIES
What activities are you having difficulty with due to your pain?
*
Going to work
Driving
Performing household chores
Exercising
Recreational Activities
Self Care
Lifting anything
Sitting
Bending
Sleeping
I do not have any difficulty with these activities
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REVIEW OF SYSTEMS
GENERAL
*
Weight gain
Weight loss
Decreased energy
Fever
None
SKIN
*
Rash
Itching
Color Change
Excessive Sweating
None
HEAD-ENT
*
Headache
Dizziness
Fainting
Blurry Vision
Sensitivity to Light
Hearing Loss
Ringing in Ears
Nose Bleeds
Bleeding Gums
None
GASTROINTESTINAL
*
Poor appetite
Painful swallowing
Abdominal pain
Heartburn
Nausea / Vomiting
Diarrhea
Constipation
Hemorrhoids
Blood in stool
None
CARDIOVASCULAR
*
Chest pain
Palpitations
Swelling in legs
Poor circulation in legs
Varicose veins
Blood clots in legs
None
RESPIRATORY
*
Shortness of breath
Painful breathing
Cough
Sputum
Cough with blood
Wheezing
None
NEUROLOGIC
*
Seizures
Fainting
Tremors
Weakness
Tingling
Numbness
Memory loss
Coordination loss
Difficulty in Walking
None
GENITOURINARY
*
Difficult urination
Flank or pubic pain
Urgency or frequency
Urine Incontinence
Night time urination
Passage of stones
Dark or bloody urine
Erectile dysfunction
Abnormal vaginal bleeding
None
PSYCHIATRIC
*
Hallucinations
Depression
Irritability
Tension or anxiety
Suicidal thoughts
Suicidal attempts
None
MUSCULOSKELETAL
*
Painful muscle(s)
Painful joint(s)
Muscle cramps
Decrease in muscle size
Joint stiffness
Joint swelling / redness
None
ENDOCRINE
*
Increase Thirst
Cold intolerance
None
HEMAT - LYMPHATIC
*
Easy Bruising
Bleeding tendency
None
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MEDICAL HISTORY
SELECT / LIST YOUR MEDICAL HISTORY:
*
High Cholesterol
Asthma
Hypertension
Acid Reflux
Hepatitis
Osteoporosis
Bleeding Disorder
Hypothyroidism
COPD / Emphysema
Heart Disease
Kidney Disease
Diabetes
Osteoarthritis
Depression / Anxiety
None
If you selected any of the boxes for the previous question, please provide any additional details that may be relevant below.
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SURGICAL PROCEDURE HISTORY
Document any surgical procedures you have had (if possible, by dates) - If you have not had any surgical procedures, please write, "NONE"
*
ALLERGIES
Allergies
*
Yes, I have allergies
No, I do not have allergies
If yes to previous question, please tell us what you are allergic to and the reaction you have:
MEDICATION LIST
Please list any medications you are currently taking, with their doses and number of times taken per day. Include "over the counter" drugs and herbal supplements. If you are not taking any medication, please type "N/A".
*
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FAMILY HISTORY
Are any of your family members currently suffering from or have passed away from the following? If so, please enter their relationship to you in the box below.
Cancer
Diabetes
Kidney disease
Chronic Pain
Alcohol Abuse
Illegal Drug Abuse
Prescription Drug Abuse
PERSONAL HISTORY
If you are currently working, please enter your occupation below.
If you are currently on disability OR have a pending application please enter the reason for disability.
If you have an open Worker’s Compensation case please click the box below.
Worker's Compensation
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LEGAL
If you have a pending litigation related to your pain click the box below.
Litigation
If you have an attorney for your pending litigation related to your pain, please enter your attorney's first and last name below.
First Name
Last Name
LIVING STATUS
*
I live alone
I live with my spouse
I live with a Domestic Partner / Friend / Kid(s)
PERSONAL HABITS / INFORMATION
Tobacco Use
*
I do not smoke
1 - 5 Cigarettes Per Day
5-10 Cigarettes Per Day
10 or more Cigarettes Per Day
Alcohol Use
*
I do not consume alcohol
1 - 2 Drinks Per Month
1 - 2 Drinks Per Week
3 - 4 Drinks Per Week
5 - 6 Drinks Per Week
1 - 3 Drinks Per Day
4 - 6 Drinks Per Day
7 - 9 Drinks Per Day
10 or more Drinks Per Day
If you have a history of using street drugs, please list them in the box below,
Please enter the date you last used street drugs.
-
Month
-
Day
Year
Date
Please select any of the options below that apply to you.
I have been addicted to prescription drugs in past
I have been treated for alcohol/ drug abuse in past
I have been sexually abused in past
Type a question
Please run the wizard
Submit
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