NEW PATIENT CANDIDACY FORM

Name:*

First NameMiddle NameLast Name

Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Home Phone Number:*

Area CodePhone Number

Cell Phone Number:

Area CodePhone Number

E-mail:*

Birth Date*

MonthDayYear

Sex:

MaleFemale

Primary Care Physician:

Referred by:*

Type of Medical Insurance*

Type of Medicare*

Name of Private/Commercial Insurance*

Plan Number*

Subscriber ID*

Law Firm/Attorney for Personal Injury Case*

Name of Law Firm or Attorney

Law Firm/Attorney Phone Number*

Area CodePhone Number

Worker's Comp Case Adjuster Name*

First & Last Name

Worker's Comp Case Adjuster Phone Number*

Area CodePhone Number

Occupation:*

Employer:*

Pain Complaints (select all that apply)*

Are You/Were You in a Pain Clinic? Or Being Prescribed Pain Medications by a Doctor?*

YesNo

Do you have a history of cancer?

YesNo

Do you have a history of diabetes?

YesNo

Do you have a history of irregular heartbeat?

YesNo

Do you have a history of chest pain?

YesNo

Do you have a history of a bleeding disorder?

YesNo

Do you have a history of high blood pressure?

YesNo

Do you have a history of heart failure?

YesNo

Do you have a history of a heart attack(s)?

YesNo

Do you have a history of having a stroke?

YesNo

Do you have a history of asthma?

YesNo

Do you have a history of COPD?

YesNo

Do you have a history of osteoporosis?

YesNo

Do you have a history of arthritis?

YesNo

Do you have a history of kidney disease?

YesNo

Do you have a history of stomach ulcers?

YesNo

Do you have a history of reflux?

YesNo

Do you have a history of HIV/AIDS?

YesNo

Do you have a history of anxiety?

YesNo

Do you have a history of depression?

YesNo

Past Surgical History - Have you ever had a/an:

If applicable, please provide the dates and details for the aforementioned procedures below:

Name of Previous Pain Clinic or Doctor*

Reason for Transferring Care*

Have You Ever Been Discharged or Dismissed from a Pain Clinic?*

YesNo

Reason for Dismissal*

Failed Drug TestIllegal DrugsMissed Pill CountFilled Pain Medications from other Doctor(s)

What Pain Medications Have You Taken Before? (select all that apply)*

If applicable, please provide the dates and details behind taking the aforementioned medications below:

Please describe the nature of your pain below:*

How long have you been in pain?*

How often do you have your pain?*

Constantly (100% of the time)Intermittently (50% of the time)Waxes and WanesNone of the above

What activities are you unable to do well because of your pain? (Select all that apply)*

What activities make your pain worse? (Select all that apply)*

What activities make your pain better?*

Constitutional Symptoms - Check the box if you are experiencing:

Eyes:

Blurred visionChanges in visionDry eyesEye pain

Ears, Nose, Mouth, Throat:

Cardiovascular:

Chest painFaintingPalpiatationsSwelling in legs/feet

Respiratory:

CoughShortness of breathWheezing

Gastrointestinal:

Genitourinary:

Difficulty urinatingImpotencePainful urinationIncontinence of urine

Muscoskeletal

Integumentary:

Neurological:

Psychiatric:

Endocrine:

Easy bruisingExcessive thirst

Hematologic/Lymphatic:

Bleeding disorderBlood clotVaricose veins

Allergic, Immunologic:

What Procedures or Surgeries Have You Had For Your Pain?*

Would You Like Injections or Procedures to Better Manage Your Pain?*

YesNo

Have You Had MRI/CT or X-rays of the Areas You Have Pain?

Yes (within the last 2 years)NoOther

Name of Facilities MRI/CT or X-rays Were Done For Each

Date:

MonthDayYear

Time

:HourMinutesAM/PM Option

NEW PATIENT CANDIDACY FORM

Insurance Information

Appointment Details

Medical History

Patient Pain Self Evaluation

Symptoms

Procedures/Surgeries

Imaging