• HPI Form

    • Personal Information 

    • Personal Information

    • Date of Birth*
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    • Do you have any medication allergies?*
    • Do you have any food allergies?*
    • Do you have allergies to IV Contrast or Iodine?*
    • As a new patient, our office requires you to provide a list of your current medications. Please select the method that works best for you.
    • List your current medications, including any over the counter and dietary supplements with the strength and dosing instructions: (ex: Tylenol 325mg, take 1 tablet 4 times a day as needed)*
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    • Family Health History

    • Mother
    • Father
    • Brother(s)
    • Sister(s)
    • Maternal Grandmother
    • Maternal Grandfather
    • Paternal Grandmother
    • Paternal Grandfather
    • For other

    • Social History

    • Are you currently employed?*
    • Are you disabled?*
    • Are you retired?*
    • Is this a work-related injury?*
    • Is there an active legal case/atty or worker's injury claim going on?
    • Is this an auto accident-related injury?*
    • Do you have difficulty walking or climbing stairs?*
    • Do you live alone or with others?*

    • Past Surgical History

    • Do you have any implanted mechanical or battery operated devices, not including any joint replacements?*
    • Please select surgical procedures you've had in the past with their approximate dates and the names of the performing surgeons, if known:
      Rows

    • Past Medical History

    • Have you ever had a Mammogram?*
    • Have you ever had a Colonoscopy?*
    • Have you had a Flu Vaccine in the past 12 months?*
    • Have you had a Pneumonia Vaccine in the past 12 months?*

    • COVID-19 Screening

      Your health is our priority. Please let us know about any recent symptoms or exposure to COVID-19.*Symptoms of COVID-19 include: Fevers or chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea
    • Are you feeling sick today? Includes any NEW symptom(s) among those listed previously that are NOT due to another health problem*
    • Have you tested positive for COVID-19 in the past 10 days?*
    • In the last 10 days, have you been exposed to someone who has tested positive for COVID-19?*
    • Have you had or are you scheduled for the Covid-19 vaccines?*
    • Date of Covid-19 vaccine*
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    • Past Medical History:*
    • Do you currently have an active infection/rash?*
    • Format: (000) 000-0000.
    • Are you currently on blood thinners?*
    • Which blood thinners?*
    • Format: (000) 000-0000.
    • Are you Left or Right Handed?*
    • History of Present Illness 

    • History of Present Illness

    • Chief Complaint (Reason for visit) :
    • You may also help us visualize the location of your pain by shading the body part in the image provided below.
    • Does your pain radiate into your Arm(s) or Leg(s)?*
    • Where does your pain radiate into?*
    • Which of the following activities are you not able to perform?*
    • Do you experience any of the following?*
    • When is your pain worse?*
    • What makes your pain worse?*
    • What makes your pain better?*
    • How would you describe your pain?*

    • On a scale of 0-10, 0 being no pain and 10 being the worst pain you can imagine.

    • Describe your pain at its worst:*
    • Describe your pain on average:*
    • Medications 

    • Medications

    • Have you previously tried or are you currently taking any over-the-counter medications to treat your pain? Example: acetaminophen, Aleve, Advil...*
    • Please list down these over-the-counter medications:
    • Please list down these over-the-counter medications
    • Have you taken any prescription medication for your pain?*
    • Please list down these prescription medications:
    • Please list down these prescription medications, approxiamte date tried(mm/yy), approximate relief(ex.50%), still using these meds?(y/n):
    • Conservative Treatments 

    • Conservative Treatments

    • Have you tried physical therapy for this pain?*
    • Are you currently attending physical therapy for this pain?*
    • Have you tried home exercises for this pain?*
    • Are you currently in a home exercise program for this pain?*
    • Have you tried chiropractic treatment for this pain?*
    • Are you currently having chiropractic treatments?*
    • Have you tried acupuncture for this pain?*
    • Are you currently having acupuncture treatments?*
    • Other Treatment Modalities 

    • Other Treatment Modalities

    • Have you tried TENS unit for this pain?*
    • Are you currently using a TENS unit?*
    • Have you tried heat for this pain?*
    • Have you tried ice for this pain?*
    • Procedures and Surgical Interventions 

    • Procedures and Surgical Interventions

    • Have you tried spinal injection(s) for this pain?*
    • Spinal Injection(s)*
    • Have you had spine surgery for this pain?*
    • Imaging  

    • Imaging

    • Please list any of the following imaging studies in relation to this pain:

    • Have you had MRI Scan for this pain?*
    • Approximate month & year and the name of the facility where MRI was performed:*
    • Approximate month & year and the name of the facility where MRI was performed:
    • Have you had CT Scan for this pain?*
    • Approximate month & year and the name of the facility where Ct Scan was performed:*
    • Approximate month & year and the name of the facility where CT Scan was performed:
    • Have you had X-ray for this pain?*
    • Approximate month & year and the name of the facility where X-ray was performed:*
    • Approximate month & year and the name of the facility where X-ray was performed:
    • I have not had ANY diagnostic tests for my current pain complaint
    • New Patient Evaluation Agreement 

    • New Patient Evaluation Agreement

    • NOTE: For the signature 

      For Computer users: You may use your mouse by holding down the left click button and use it like a pen signing on a paper make sure you are not going outside the signature box when signing.

      If Using Mobile: Use your finger as a pen to sign inside the box and make sure you are not going outside the signature box when signing.

    • Signature
    • Date
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