New Patient Form

HPI Form

Personal Information
Personal Information
Full Name*
First NameMiddle NameLast Name
Date of Birth*
MonthDayYear
E-mail
example@example.com
Do you have any medication allergies?*
YesNo
Please list your allergies and briefly describe the reaction you have:
example: rash, swelling, swelling, difficulty breathing, etc.
Do you have any food allergies?*
YesNo
Please list your food allergies and briefly describe the reaction you have:
example: rash, swelling, swelling, difficulty breathing, etc.
Do you have allergies to IV Contrast or Iodine?*
YesNo
Please explain:*
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.
Upload a photo of my medication listBring a printed list of my medications to my appointmentI am ready to list down my current medicationsI am not currently taking any medications
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)*
You can also upload your medication list
Cancelof
How tall are you?*
What is your current weight?*
Family Health History
Mother
For other *
Father
For other *
Brother(s)
For other *
Sister(s)
For other *
Maternal Grandmother
For other *
Maternal Grandfather
For other *
Paternal Grandmother
For other *
Paternal Grandfather
For other *
Other
Relationship
For other
For other *
Social History
Tobacco Status*
How much do you smoke?*
For Other*
Comment
When did you stop smoking?
Approximate month/year
Have you ever used smokeless tobacco?*
How long have you used tobacco products?
Comment
Have you ever used e-cigarettes or vapes?*
Comment
How often do you drink alcohol*
How long have you been consuming alcoholic beverages?*
Have you ever used illicit drugs?*
Please explain
Have you ever had a problem with substance abuse?*
Please explain
Are you currently employed?*
YesNo
What is your occupation?*
What is your employment status?*
Other
Are you disabled?*
YesNo
Are you retired?*
YesNo
Is this a work-related injury?*
YesNo
Approximate month and year of injury and brief description:
Have you experienced a similar pain complaint prior to this injury?
Is there an active legal case/atty or worker's injury claim going on?
YesNo
Is this an auto accident-related injury?*
YesNo
Approximate month and year of injury and brief description:
Have you experienced a similar pain complaint prior to this accident?
Do you have difficulty walking or climbing stairs?*
YesNo
Do you live alone or with others?*
Live aloneWith others
With Others:
Relationship
Marital Status*
Number of Children*
Past Surgical History
Do you have any implanted mechanical or battery operated devices, not including any joint replacements?*
YesNo
If Yes, please specify using the space below and bring your device card at the time of your appointment to be scanned into your chart*
Please select surgical procedures you've had in the past with their approximate dates and the names of the performing surgeons, if known:
Select Approximate Date Performing Surgeon
Appendectomy 1
Tonsillectomy 2
Gallbladder surgery 3
Knee surgery 4
Back surgery 5
Neck surgery 6
Hysterectomy 7
Cesarean section 8
Please list any other surgical procedures you've had in the past with their approximate dates and the names of the performing surgeons, if known:
approximate month and year
Past Medical History
Have you ever had a Mammogram?*
YesNoNot Applicable
Approximate month and year of Mammogram
Have you ever had a Colonoscopy?*
YesNoNot Applicable
Approximate month and year of Colonoscopy
Have you had a Flu Vaccine in the past 12 months?*
YesNo
Approximate date of Flu Vaccine
Have you had a Pneumonia Vaccine in the past 12 months?*
YesNoNot Applicable
Approximate month and year of Pneumonia Vaccine
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*
YesNo
Have you tested positive for COVID-19 in the past 10 days?*
YesNo
In the last 10 days, have you been exposed to someone who has tested positive for COVID-19?*
YesNo
Have you had or are you scheduled for the Covid-19 vaccines?*
YesNo
Date of Covid-19 vaccine*
MonthDayYear
Past Medical History:*
AIDS/HIVAcid Reflux (GERD)Anxiety/DepressionArthritisAsthmaBleeding DisorderCancerCOPDCoronary Artery DiseaseDiabetesFibromyalgiaGoutHeart Attack (MI)Heart DiseaseHepatitisHyperlipidemiaHypertensionKidney DiseaseLiver diseaseLupusOsteoperosisRheumatoid ArthritisSeizuresStrokeThyroid ProblemsUlcersNone KnownOther
What type of cancer?
Do you currently have an active infection/rash?*
YesNo
What medications (antibiotics) are you taking for that?*
Name of the prescriber *
Prescriber contact number*
Are you currently on blood thinners?*
YesNo
Which blood thinners?*
Aspirin (if taking more than 325 mg daily)BC powderHeparinLovenoxAggrenoxPlavixPletalEffientTiclidPersantineSavaysaTrentalBrilintaCoumadinPradaxaEliquisXareltoOther
Name of the prescriber *
Prescriber contact number*
Are you Left or Right Handed?*
RightLeftBoth

	Select	Approximate Date	Performing Surgeon
Appendectomy	1
Tonsillectomy	2
Gallbladder surgery	3
Knee surgery	4
Back surgery	5
Neck surgery	6
Hysterectomy	7
Cesarean section	8

Medications
Medications
Have you previously tried or are you currently taking any over-the-counter medications to treat your pain? Example: acetaminophen, Aleve, Advil...*
YesNo
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?*
YesNo
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):

Other Treatment Modalities
Other Treatment Modalities
Have you tried TENS unit for this pain?*
YesNo
Are you currently using a TENS unit?*
YesNo
Approximate date tried*
month/year
# of weeks tried*
Approximate % of relief*
Have you tried heat for this pain?*
YesNo
Approximate date tried*
month/year
# of weeks tried*
Approximate % of relief*
Have you tried ice for this pain?*
YesNo
Approximate date tried*
month/year
# of weeks tried*
Approximate % of relief*
Other Treatment modalities you have tried
ex.Iontophoresis, Ultrasound, Phonophoresis, Electrical Stimulation, etc.

Procedures and Surgical Interventions
Procedures and Surgical Interventions
Have you tried spinal injection(s) for this pain?*
YesNo
Spinal Injection(s)*
Have you had spine surgery for this pain?*
YesNo
Approximate date of surgery*
Type/Body location of surgery (if known)
Ex. Left Knee Surgery
Name if Doctor (If known)
% of relief*
Ex. 80 % relief, 100% relief or no relief
Duration of relief*
Ex. 2 Weeks

Imaging
Imaging
Please list any of the following imaging studies in relation to this pain:
Have you had MRI Scan for this pain?*
YesNo
Region of the body where MRI was performed
(Ex. Neck, back, head, hips, legs, foot, etc.)
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?*
YesNo
Region of the body where CT Scan was performed
(Ex. Neck, back, head, hips, legs, foot, etc.)
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?*
YesNo
Region of the body where X-ray was performed
(Ex. Neck, back, head, hips, legs, foot, etc.)
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
YesNo
What are your expectations for your visit?

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.
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Signature
Date
MonthDayYear
Should be Empty:

HPI Form

Personal Information

Family Health History

Social History

Past Surgical History

Past Medical History

COVID-19 Screening

History of Present Illness

Medications

Conservative Treatments

Other Treatment Modalities

Procedures and Surgical Interventions

Imaging

New Patient Evaluation Agreement