First Name
*
Date of Birth (MM/DD/YYYY)
*
Last Name
*
Social Security Number
Patient Sex
*
Male
Female
Cell-Phone
*
Work Phone
Email
*
Address Line #1
Address Line #2
City
State
Postal code
Country
Country
Emergency Contact
*
First Name
Last Name
Phone Number
Address
City, State
Zipcode
Emergency Contact's Relation to Patient
Primary Care Physician (PCP)
Primary Care Physician Name
PCP's Office Number
Referring Physician
Referring Physician Phone Number
Have you done any imaging that relates to your current pain condition or possible injuries? (CT, MRI)
Yes
No
Other
If you have done imaging, what type did you receive?
Do you have a print-out copy of the imaging report?
If you have done imaging, please list the facility you got it performed at
Imaging Facility Address
Imaging Facility Number
Insurance Information
Primary Insurance
Insurance ID #
Insured Name
Relation to Patient
DOB
Secondary Insurance
Insurance ID#
Insured's Name
Relationship to Patient
DOB
Person Responsible for any Balances
Address (if different from Patient)
Workman's Comp/Liability (If Applicable)
Date of Injury (mm/dd/yyyy)
Claim #
Case Manager:
Employer
Phone Number
Street Address
City, State
Postal Code
Workman's Comp Insurance
Phone Number
Attorney's First Name
Attorney's Last Name
Attorney's Phone Number
Preferred Pharmacy
Name of Pharmacy
Address
City, State
Postal Code
Location of Pain
Upper Back
Middle Back
Lower Back
Neck
Shoulders
Arms
Legs
Knee
Jaw
Other
How would you describe your pain?
Aching
Numbing
Pins and Needles
Burning
Stabbing
Other
Other (Indicate description of pain)
Approximately when did your pain start?
Is your pain a result of an injury?
Yes
No
Date of Injury
Pain is:
Constant
Intermittent
On a scale of 1-10, rate your pain
What Increases Your Pain?
Sitting
Standing
Walking
Getting up
Strenuous Movements (lifting, working out etc.)
What Decreases Your Pain?
Sitting
Walking
Standing
Laying Down
Medication, Acupuncture, etc
Has your pain increased over time?
Yes
No
Do you have issues sleeping due to your pain?
Yes
No
Do you have any bowel or bladder problems?
Yes
No
As of today, what have you done to help relieve your pain?
Acupuncture
Physical Therapy
Chiropractor
Massage Therapy
Medications
TENS Unit
Ice
Heat
Other
Previous Treatments
Spine Surgery
Epidural Steroid Injection
Acupuncture
Are you currently taking any blood thinners?
Yes
No
Medical History
*
Arthritis (Rheumatoid, Osteoarthritis, Gout, Fibromyalgia, Childhood Arthritis)
Asthma
Bleeding Disorders
Cancer
COPD
Chest Pain/Tightness
Diabetes
HIV/AIDS
High Blood Pressure (Hypertension)
Liver Disease
Thyroid Disease
Neurological Disorders (Seizures, Autism, ADHD, etc.)
Stomach Ulcers
Any contagious disease
Other
Allergies
*
Drug-Related Allergies
Non-Drug Related Allergies
IV Contrast, Dye, Shellfish
List all Current Medications (Include Dosages, Topicals, and Vitamins)
Surgeries
1) Surgery + Date (MM/YYYY)
2) Surgery + Date (MM/YYYY)
3) Surgery + Date (MM/YYYY)
4) Surgery + Date (MM/YYYY)
Recent Hospitalizations (MM/YYYY + Reason)
1)
2)
3)
4)
5)
Do you smoke?
Current Smoker
Non-Smoker
Former Smoker
If yes, how much do you smoke per week?
Do you have a history of substance abuse?
No
Alcohol Abuse
Illicit Drug Abuse
Other
Do you drink alcohol?
*
None
Rarely
Socially
Other
With whom do you live with?
*
Alone
Spouse/Children
Roommates
Other
Occupation
*
Full-Time
Part-Time
Homemaker
Retired
Disabled
Other
How did you hear about Chicago Sports and Spine?
Family/Friend
Physician
Insurance
Website
Other
Marital Status
*
Single
Married
Divorced
Widowed
Imaging Report, Physician Referral, Images of ID and Insurance
PDF, PNG, JPEG, JPG, DOCX or DOC
Signature of Patient or Legal Representative
*
Clear
Today's Date
*
Submit
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