Patient Data Sheet. Emergency Contact Name: Relationship: Contact phone number: Name: Specialty: Office address: Office phone: Fax:

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1 Today s Date: / / Your Information Patient Data Sheet Last ame: First: MI: Sex: M F Date of Birth: / / Age: SS: Address: Home phone: Cell phone: Can we leave message on Home? Y or Cell? Y Are you currently employed? Y ame of Employer: Occupation: Emergency Contact ame: Relationship: Contact phone number: Referring Physician ame: Specialty: Office address: Office phone: Fax: Primary Care Provider (PCP) ame: Specialty: Office address: Office phone: Fax: Insurance Information Primary Insurance Company: ID#: Group #: Subscriber s ame: Subscriber s DOB: Subscriber s SS: Relationship to Subscriber: Secondary Insurance Company (if applicable) ID#: Group #: Page1

2 Past Medical History (please circle) Cardiovascular system: high blood pressure, angina, heart attack, heart failure, irregular heartbeat, heart murmur, other Respiratory system: asthma, bronchitis, emphysema/copd, pneumonia, other Digestive system: acid reflux (GERD), stomach ulcer or gastritis, hepatitis, pancreatitis, gall bladder problem, other Urinary system: kidney stone, urinary tract infection, enlarged prostate, bladder problem, other eurological system: stroke, headache, syncope (pass out), seizure, movement disorder, dementia, other Endocrine system: diabetes, thyroid problem, high cholesterol, other Musculoskeletal system: joint pain, joint swelling, joint stiffness, fracture, arthritis, chronic back pain, fibromyalgia, other Rheumatology disease: lupus, rheumatoid arthritis, other Hematology & Oncology: cancer, bleeding disorder, bone marrow disorder, DVT (clot in deep vein), PE (clot in the lung), taking blood thinner (aspirin, Plavix, Coumadin, etc.), other Psychiatric system: depression, anxiety, bipolar, post-traumatic stress disorder (PTSD), obsessive compulsive disorder (OCD), drug addiction, other Past Surgery History (please list ALL previous surgeries with dates) Allergy: Page2

3 Pain medications: please list ALL medications you are currently taking for Pain including over the counter medications and herbs. ame of Drug Dose Frequency Prescriber for the drug Please list all the pain medications you took in the past and reason for discontinuation: Pharmacy Information ame: Address: Phone number: Fax: Pain Treatment History Besides medication, what other modalities are you using to manage pain? Ice pack or heating pad patch or ointment TES unit Acupuncture massage physical therapy Chiropractic biofeedback Yoga, Qigong, Pirate Psychotherapy naturopathic pain procedures (below) Have you had any of pain procedures (epidurals or nerve blocks) in the past? Y If yes, what procedure, when, where and with whom? Was it helpful? Y How long did the pain relief last? Did you see any pain specialists in the past? Can we request your medical record from your previous pain physician s office? Y If yes, please sign the attached Release of Information form. Page3

4 Pain Description: Location (where): Duration (how long): Onset (when and how did it start): Page4

5 Is this work-related injury? Y Works-comp attorney Is the pain constant or intermittent (come and go)? Radiation? Y Description of the pain (i.e. sharp, dull, stabbing, achy, throbbing, etc.) Severity of pain: number your pain using the pain score scale below Worse pain score? /10 Best pain score? /10 Average /10 What makes the pain better? (i.e. heat, cold, medication, resting, etc.) What makes the pain worse? Have you ever experienced any numbness or tingling in any part of your body? Y Have you ever experienced any weakness in your arms or legs? Y Have you ever lost control of your bowel or bladder? Y Signature: Print: Date: Page5

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