GUPTA SPORTS & SPINE CENTER

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GUPTA SPORTS & SPINE CENTER NEW PATIENT INFORMATION FORM -ORTHO 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? 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. What have you tried to improve your pain? (medications, therapy, other doctors) 7. Have you had any imaging (X-Ray, MRI, etc) done for this area? And if so where and when?

Patient Name page 4 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 type) Peripheral Vascular Dz Hyperthyroidism Irritable Bowel Blood Clots /DVT Enlarged Prostate/BPH Anxiety Other High Cholesterol Osteoporosis Depression 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 5 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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