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1031 WEST WILLIAMS STREET, SUITE 102, APEX, NC 27502 PHONE (919) 439-7867 FAX (919) 573-9594 NEW PATIENT INFORMATION FORM All patients (new and returning) are subject to the following no-show/broken appointment policy. Your completion of this form indicates that you acknowledge and fully understand this policy. When an appointment is made for a patient to be seen in our office, a specific time is reserved for that patient. This allows the provider to meet the patient s needs. Broken or missed appointments result in the loss of valuable time that could be spent with patients in need of treatment. For this reason, if a patient fails to keep a NEW PATIENT VISIT, he or she will be charged a fee of $250. If a patient fails to keep a FOLLOW-UP VISIT, he or she will be charged a fee of $100. If a patient fails to keep an appointment for a PROCEDURE, he or she will be charged a fee of $150. If a no-show fee is not paid within 60 (sixty) days, the patient will be charged an additional $10 late payment fee. If an appointment needs to be cancelled or rescheduled for any reason, please notify our office at least 24 hours in advance, and no fee will be charged. If a patient misses more than 3 (three) appointments without prior notice, that patient may be dismissed from the practice. We ask that all NEW PATIENTS bring recent imaging reports (MRI s, CT, X-Ray, EMG, etc.) to their first visit. Also, please bring ALL CURRENT MEDICATIONS within their ORIGINAL PILL BOTTLES. Failure to do so will mean that we cannot prescribe medications on the first visit and treatment will be delayed. Name: E-Mail Address: Today s date: Date of birth: Sex: How did you hear about Atlantic Spine & Pain? Referring physician: Primary care physician (if different): Please indicate your primary pharmacy (name & location): What approximate date did your pain start? Did your pain start suddenly or gradually?

List your PRIMARY and SECONDARY areas of pain: PRIMARY SECONDARY Neck Pain Upper Back Low Back Pain Shoulder Pain Elbow Pain Wrist Pain Hand Pain Hip Pain Knee Pain Ankle Pain Foot Pain Abdominal Pain Pelvic Pain Chronic Pain Headaches Peripheral Neuropathy List OTHER areas of pain: Which SIDE is your Primary pain? Right Left Both Which SIDE is your SECONDARY pain? Right Left Both What evaluation and treatments are you interested in? Pain Management by Medication Injections Botox for Migraine Prolotherapy Platelet Rich Plasma PT referral Diagnostic Testing (EMG/NCV, X-Ray, MRI)

My pain is due to: Car accident Surgery Lifting Injury Sports injury Work injury A Fall Other Which of the following best describes your pain? Constant Frequent Intermittent Occasional How severe is your pain right now: Select all that describes you current pain. Burning Throbbing Dull/Aching Shooting Sharp Cramping Pressure Lightening Like Electric Cutting Numbness Tingling Insomnia Other If your pain is radiating, where does it travel? Please shade in the location(s) of your pain:

Is your pain associated with? Numbness. Where? Tingling. Where? Weakness. Where? Bladder or bowel dysfunction? Known reactions to anesthetics? History of cardio-defibrillator? History of pacemaker? Is sleep affected by your pain? Are you currently taking any blood thinners? Do you have an allergy to shellfish? Do you have known reactions to radiographic contrast? Do you have diabetes? How do each of the following affect your pain? Lying down Standing Sitting Walking Exercise Medications Relaxation Thinking about something else Coughing/Sneezing Urination Bowel Movement Relieves Pain Worsens Pain No Effect

Have you ever been treated by a pain specialist before? If yes, where and when? Why did you leave? What treatments have been attempted in the past? Excellent Relief Moderate Relief Minimal Relief No Relief Bedrest Traction Back Brace TENS Unit Physical Therapy Exercise Ice Heat Corticosteroid Injection Cervical Facet Injection Epidural Injection Lumbar Facet Injection Nerve Block Surgery Chiropractic Acupunture Psychotherapy Biofeedback Hypnosis Prolotherapy Platelet Rich Plasma Other: What medications have been taken to relieve pain in the past? Excellent Relief Moderate Relief Minimal Relief No Relief Cymbalta (Duloxetine) Effexor (Venlafaxine) Savella (Milnacipran) Amitriptyline Nortriptyline Desipramine Neurontin (Gabapentin) Lyrica (Pregabalin) Topiramate Lamotrigine Carbamazepine Oxcarbazepine Zonisamide Keppra (Levitracetam) Beta Blockers (Propranolol)

Calcium Channel Blockers ACE Inhibitors Ergotamines Triptans Ibuprofen Naproxen Diclofenac Celecoxib (Celebrex) Meloxicam (Mobic) Nabumetone (Relafen) Indomethacin Ketorolac (Toradol) Voltaren Gel Flector Patch Aspirin Baclofen Cyclobenzaprine (Flexeril) Carisoprodol (Soma) Methocarbamol (Robaxin) Metaxalone (Skelaxin) Tizanidine (Zanaflex) Diazepam (Valium) Tramadol (Ultram) Hydrocodone (Vicodin, Lortab, Norco) Oxycodone (Lorcet, Roxicet) Oxycontin Percocet Fentanyl (Duragesic) Hydromorphone (Dilaudid) Exalgo Tapentadol Propoxyphene (Darvon) Methadone Acetaminophen Licoderm Past medical history: Please indicate all chronic medical conditions (e.g. diabetes, hypertension, depression). Hypertension Chronic Renal Fail Osteoarthritis CHF Hepatitis HIV Coronary Artery Disease Cirrhosis Depression Prior MI GERD Anxiety Stroke IBS Panic Attacks COPD Obesity Hypercholesterolemia Sleep apnea Diabetes Migraines

Nicotine Dependence Cancer Insomnia Asthma Hypothyroidism Denial of Past Medical History Other: Past surgical history: Please list all operations, and the date performed. Neck Surgery Hemorrhoidectomy Osteoarthritis Back Surgery Hysterectomy Tubal Ligation Cervical Fusion Cardiac Cath Pacemaker Lumbar Laminectomy Cholecystectomy Tonsillectomy Lumbar Fusion Lung surgery Heart Valve Replacement Gastric Bypass C-Section Hip Replacement CABG Thyroid Surgery Knee Replacement Appendectomy Carotid Surgery Knee Arthroscopy Inguinal Hernia Repair Cataract Denial of Past Medical History Other Surgical History: Past imaging history: Please indicate all MRIs, X-Rays, EMGs and CTs related to your current pain. Please list type and facility Date Medications: Please list ALL medicines you currently take, including vitamins, supplements, and over-the-counter drugs. Please bring your bottles with you. Medicine Dose

Allergies: Please list all allergies to medicines, animals, or environmental factors. Family History: Please list the conditions or illnesses that run in your family. Condition Relative Marital status: Married Single Divorced Widowed Do you have children? What are their ages? Living Situation? Significant Other Spouse Adult Children Alone Assisted-Living Facility Friend Education level: Diploma/GED Associates Bachelor s Master s Doctorate Do you work? Full-time Part-time Retired Disabled Unemployed If not currently working, when was the last time you worked? What are your hobbies/interests? Do you now (or have you ever) used tobacco? Type: Cigarettes Cigar Pipe Chewing tobacco Dip/snuff Amount: Start date: Quit date: Do you now (or have you ever) used alcohol? Type: Amount (drinks/week): Do you now (or have you ever) used recreational drugs? Type: Frequency: Have you ever been treated for substance abuse/dependence? Have you ever been arrested for DUI? Have you ever been arrested on drug-related charges? Have you ever undergone psychiatric or psychological counseling?

REVIEW OF SYSTEMS (check all that apply) Constitutional: No problems Fever Abnormal Appetite Trouble Sleeping Fatigue Other Eyes: No problems Blurry vision Double vision Glasses Other ENT: No problems Sore throat Hearing Changes Nose bleeds Other Cardiovascular: No problems Chest pain Palpitations Leg/Feet swelling Other Respiratory: No problems Wheezing Coughing Short of breath Other Hematologic/Lymphatic: No problems Easy bruising Easy bleeding Other Gastrointestinal: No problems Dysphagia Heartburn Nausea Vomiting Abdominal pain Diarrhea Other Genitourinary: No problems Pain w/ urination higher frequency Blood in urine Pain w/ sex Impotence Other Skin: No problems Rashes Skin lesions Other Musculoskeletal: No problems Joint pain Joint swelling Muscle aches Other Neurological: No problems Weakness Numbness Balance problems Tremor Dizziness Memory problems Headaches Seizures Other Psychiatric: No problems Depression Anxiety Mood changes Suicidal Thoughts Other

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