GUPTA SPORTS & SPINE CENTER

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GUPTA SPORTS & SPINE CENTER NEW PATIENT INFORMATION FORM -SPINE Please print all information. Thank you for your cooperation. Patient Name: Date of Birth: _ Social Security # Address: City: _ State: Zip Code: Phone (home): Work/Cell: Employer: Marital Status: Single Married Divorced Widowed Email Address: Is it ok to mail correspondence such as reminders and letters to you? Yes No Referring Physician or Referral Source: Primary Care Physician: Do you want your medical records sent to this practice? Yes No Insurance Plan: Group Number: Policy Number: Issue Date: Secondary Insurance Plan: Group Number: Policy Number: Issue Date: Thank you for taking the time to complete our intake forms. Patient s Signature Please sign & date (below) Today s Date

Patient Name page 2 Pain Drawing Instructions: Mark these drawings according to where you hurt. Please use the key below to indicate which sensations you are experiencing. Key: Stabbing //// Pins/Needles 0000 Numbness ==== Burning XXXX Aching ++++ Right Left Right Circle your current pain level and place a check next to your lowest and highest levels. 0 1 2 3 4 5 6 7 8 9 10 0 No Pain 1 Mild pain; you are aware of it, but it doesn t bother you 2 Moderate pain that you can tolerate without medication. 3 Moderate pain that requires medication to tolerate. 4-5 More severe pain; you begin to feel antisocial. 6 Severe pain. 7-9 Intensely severe pain. 10 Most severe pain

Page 3 HISTORY OF PRESENT COMPLAINT 1. Age: Male Female Pain is on which side: Right Left 2. Where is your problem located? Neck Upper Back Arm Lower back Hip Leg 3. How long have you had this problem? Since? 4. Briefly, please give the details of how this problem originally started: _ 5. Please describe your present pain/problem now (what you feel, where, when, etc.) _ 6. Was this from a work-related injury? No Yes If yes, is it under worker s comp? Yes No. 7. Have you had spinal surgery in the past: No Yes What type of surgery was performed? Did you improve from your spine surgery procedure? Yes No 8. Which of the following best describes your ratio for neck & arm or back & leg discomfort? (example 75% back/neck pain and 25% leg/arm pain) 9. For any pain/numbness in your arm(s) or leg(s) which side is worse? (example 90% right arm/leg and 10% left arm/leg) 10. Have you had any past episodes of similar pain or injury? Yes No Please describe below: 11. Have the symptoms of your present pain: improved remained the same worsened 12. What imaging or studies have you had done for this in the past (X-ray, MRI, EMG, etc)? 13. List all other physicians with whom you have consulted in the past year for this problem.

Page 4 CURRENT PAIN PROFILE 14. Please choose letters A-F (in first column) to answer the questions in column two. A. Unable to tolerate B. About 15 minutes only How long can you sit? C. About 30 minutes only D. About 45 minutes only How long can you stand? E. About 1 hour F. Indefinitely How long can you walk? 15. Which of the following activities change the nature of your pain? Aggravates Pain Relieves Pain Neither Sitting Standing Walking Bending forward Leaning forward (brushing teeth) Lying on your side Lying on your back Lying on your stomach Rising from sitting Changing positions Coughing/sneezing Driving 14. Of the following list of treatments, please indicate the effect of those which have been used in an attempt to help your present injury: (check one of each) Which Type Helpful No Help Not Used Anti-inflammatory Muscle Relaxants Narcotic Pain Medications Hot Packs Ice Ultrasound Tens Unit/Muscle stim (circle) Physical Therapy Treatment Back/Neck Exercises Chiropractor Epidural Block/Injection Facet Block/Injection SI Joint Block/Injection Trigger Point Injection Acupuncture/ Massage Traction/VAX-D (circle one)

Patient Name page 5 Past Medical History: No Medical History COPD Kidney Disease Seizures Please circle all that apply Emphysema Stroke/CVA Osteoarthritis Hypertension Obstructive Sleep Apnea Headaches/Migraines Rheumatoid Arthritis Congestive Heart Failure Hepatitis Anemia Gout Abnormal Heart Rhythm Diabetes Type 1 2 Lupus Endometriosis Heart Disease, CAD Hypothyroidism Reflux Cancer (specify) Peripheral Vascular Dz Hyperthyroidism Irritable Bowel Blood Clots /DVT Enlarged Prostate/BPH Anxiety High Cholesterol Osteoporosis Depression Other Past Surgical History: No Surgical History Tonsil Eye Hip Replacement Please circle all that apply Thyroid Ear Knee Surgery Heart Bypass Appendix Prostate Neck Surgery Fusion Heart Pacemaker Gallbladder Kidney Back Surgery Fusion Angioplasty Stent Gastric Bypass Bladder Other Brain Hysterectomy Hernia Lung C-Section Shoulder Rotator Cuff Family History: Relative Age/Living Health Problems Father Mother Brother Sister Allergies (to medications and food) Medications: (please include all herbal supplements and/or vitamins)

page 6 SOCIAL HISTORY 1. Current work status Occupation: 2. Marital Status: Single Married Divorced Widowed 3. Number of Children: 4. I live: Alone With: I live in a: House Apartment Nursing Facility 5. Are you a cigarette smoker? No Yes How old were you when you began smoking? How much do you smoke daily? When did you quit smoking? 6. Do you drink any alcoholic beverages: (check one) No Yes 1 2 3 4 5 6 drinks daily weekly monthly social use only 7. Have you ever had a problem with drug dependence? Yes No 8. Please write any additional information that you feel is important for us to know. REVIEW OF SYTEMS Do you currently have any of the following medical symptoms? General o Unexplained weight loss o Appetite change o Fevers or chills o Night sweats o Marked fatigue o Difficulty sleeping Eyes o Glasses o Change in vision o Double vision Ear, Nose, Throat o Difficulty swallowing o Hoarseness o Loss of hearing o Ear pain o Nosebleeds Cardiovascular o Heart or chest pain o Abnormal heartbeat o Leg swelling Respiratory o Morning cough o Shortness of breath o Productive cough or sputum Digestive o Nausea or vomiting o Stomach pain or ulcers o Heart burn o Diarrhea o Constipation o Uncontrolled loss of stool o Blood in stools Skin o Rashes o Itchiness o Easy bruising Neurological o Seizures o Blackouts/fainting o Headaches/migraines Musculoskeletal o Joint pains o Joint swelling o Numbness in feet/hands o Muscle weakness Genitourinary o Burning on urination o Incontinence o Pelvic pain o Impotence o Abnormal Bleeding Psychiatric o Depression o Anxiety o Paranoia Other

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