New Patient Form

HIPAA Compliant Web Forms

First Name*

Last Name*

DOB

Age

Phone*

(xxx)xxx-xxxx

Email*

name@example.com

Gender

O Male

O Female

Height

Weight

SEGURA NEUROSCIENCE & PAIN CENTER

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Dominant Hand

0 Right

0 Left

Chief Complaint:

In your own words, why are you here today ...

Pain Score 1 - 10

@l

0 2

0 3

04

0 5

0 6

O 7

0 8

O 9

O 10

2

Quality of Pain: (please choose all that apply to your pain)

D Tenderness D

0 Aching D

D Burning D

D Cramping D

D Muscle weakness D

D Pins/needles D

Referring Physician

How did you hear about us?

When did the pain start?

Where is it located?

Does it radiate into your arms?

0 No

O Yes, right arm

O Yes, left arm

O Yes, both arms

Does it radiate into your legs?

0 No

O Yes, right leg

O Yes, left leg

O Yes, both legs

Pressure

Shocking

Shooting

Spasms

Stabbing

Stinging

0 Throbbing

D Tightness

0 Tingling

0 Other

3

Was this due to a MVA or Work Injury?

What makes the pain BETTER?

What makes the pain WORSE?

Do you sleep well?

O Yes

0 No

Do you fall asleep easily?

O Yes

0 No

Do you wake up easily?

O Yes

0 No

Do you have any numbness?

O Yes

0 No

If yes, where?

Do you have any weakness?

O Yes

0 No

If yes, where? 4

Do you have any bladder or bowel incontinence?

O Yes

0 No

Have you had surgery for your pain?

Past Treatments:

D Nerve Blocks

D Epidural Steroid Injection

D Chiropractor

D Physical Therapy

O Other

Other Treatment: With Whom/ How Long Ago?

Radiology Testing

D Xrays

0 MRI

0 CT Scan

Radiology Test - Where/ Date:

Smoker:

O Yes

0 No

O Quit

Packs per day:

Number of years: 5

Alcohol:

O None

O Occasional

0 Daily

How much per week:

Recreational Drugs:

O Yes

0 No

Do you have any history of prescription medication Abuse/Overuse

O Yes

0 No

Do you have any history of addiction:

O Yes

0 No

Working status:

O Currently working

O Retired

O Unemployed

0 Disabled

Occupation:

6

Please select if you have any of the following:

D Anxiety

D Depression

D Memory Loss

D Suicidal Ideation

0 ADHD/ADD

O Other

Other:

ALLERGIES:

Med i cation: _________________ Re action: _________________________ _

SURGICAL HISTORY

Year: __________ Describe: ___________________ Doctor: _________ _

8

Current Medications: List all medications you are currently taking including over the

counter medication, herbs, and vitamins. Include: Medication Name I Strength I Dose

I Prescriber

Med Name: _____________ St re n gt h: _________ Dose: _________ pre sc ri be r: ____________ _

Family Medical History: Please list any outstanding medical conditions:

Mother

Father

Siblings

Maternal Grandfather

Maternal Grandmother

Paternal Grandfather

Paternal Grandmother

Other: 9

REVIEW OF SYSTEMS: Please select if you have or had any of the following:

General

D Weight change

D Poor or changed appetite

D Severe fatigue / low energy

D Recent fevers

D Recent antibiotics

Hematological

D Anemia

D Easy bruising

D Bleeding disorder

D Taking blood thinners

D Blood transfusion

D Cancer

Skin

D Rash

D Nail changes

D Bumps/nodules

Head and Neck

D Headaches

D Visual changes

D Mouth problems

D Neck pain

D TMJ problems

10

Cardiac

D Chest pain

D Irregular heartbeat

D Heart murmurs

D High or low blood pressure

D Circulation problems

D Ankle swelling

Pulmonary

D Shortness of breath

0 Cough

D Asthma or bronchitis

D Lung disease

D Sleep apnea

D Snoring

Endocrine

D Diabetes

0 Thyroid problems

Gastrointestinal

D Adominal pain

D Nausea or Vomiting

D Constipation

D Diarrhea

D History of ulcers

D Reflux

D Heartburn

11

Genitourinary

D Frequent or hesitant urination

D Pain with urination

D Blood in urine

D Incontinence

D Sexual dysfunction

Musculoskeletal

0 Arthritis

D Osteoporosis

D Muscle pain

D Muscle wasting

D Fractures

Neurologic

D Numbness

D Weakness

D Falling

D Stroke

D Seizures

D Memory loss

D Loss of balance

Infectious Diseases

D Measles

D Mumps

D Chicken pox

D Rheumatic fever

D Hepatitis A

D Hepatitis B

D

D

D

D

D

D

D

Hepatitis C

HIV

AIDS

Herpes (oral)

Herpes (gential)

Shingles

Post-herpatic neuralgia

Gynecologic

D Pregnant

D Post Menstrual Period

12

IT IS SEGURA NEUROSCIENCE AND PAIN CENTER'S PRACTICE NOT TO PRESCRIBE

BENZODIAZEPINES (XANAX, ATIVAN, VALIUM, KLONOPIN) AND SOMA. BY CHECKING

BELOW YOU ACKNOWLEDGE THAT YOU UNDERSTAND AND ARE AWARE THAT EXTREME

SLEEPINESS, RESPIRATORY DEPRESSION, COMA, AND DEATH CAN OCCUR WITH THE USE

OF THESE MEDICATIONS AT THE SAME TIME.

Clinical guidelines from the U.S. Centers for Disease Control and Prevention (CDC) and

existing labeling warnings regarding combined use caution prescribers about co­

prescribing opiods and benzodiazepines to avoid potential serious health outcomes. The

actions of the FDA today are consistent with the CDC.

There are dangers of certain medication interactions with chronic opioid use.*

O Yes, I understand

COMM

Please answer each question as honestly as possible. Keep in mind that we are only

asking about the past thirty days. There are no right or wrong answers. If you are

unsure about how to answer the question, please give the best answer you can.

1. In the past 30 days, how often have you had trouble thinking clerarly or

had memory problems?

O Never

O Seldom

O Sometimes

O Often

O Very Often

13

2. In the past 30 days, how often do people complain that you are not completing

necessary tasks? (i.e., doing things that need to be done, such as going to class,

work, or appointments)

O Never

O Seldom

O Sometimes

O Often

O Very Often

3. In the past 30 days, how often have you had to go to someone other than your

prescribing physician to get sufficient pain relief from medications? (i.e., another

doctor, the Emergency Room, friends, street sources)

O Never

O Seldom

O Sometimes

O Often

O Very Often

4. In the past 30 days, how often have you taken your medications differently from

how they are prescribed?

O Never

O Seldom

O Sometimes

O Often

O Very Often

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5. In the past 30 days, how often have you seriously thought about hurting yourself?

O Never

O Seldom

O Sometimes

O Often

O Very Often

6. In the past 30 days, how much of your time was spent thinking about opiod

medications (having enough, taking them, dosing schedule, etc.)?

O Never

O Seldom

O Sometimes

O Often

O Very Often

7. In the past 30 days, how often have you been in an argument?

O Never

O Seldom

O Sometimes

O Often

O Very Often

8. In the past 30 days, how often have you had trouble controlling your anger (e.g.,

road rage, screaming, etc.)?

O Never

O Seldom

O Sometimes

O Often

O Very Often

15

9. In the past 30 days, how often have you needed to take pain medications

belonging to someone else?

O Never

O Seldom

O Sometimes

O Often

O Very Often

10. In the past 30 days, how often have you been worried about how you're handling

your medications?

O Never

O Seldom

O Sometimes

O Often

O Very Often

11. In the past 30 days, how often have others been worried about how you're

handling your medications?

O Never

O Seldom

O Sometimes

O Often

O Very Often

12. In the past 30 days, how often have had to make an emergency phone call or

show up at the clinic without an appointment?

O Never

O Seldom

O Sometimes

O Often

O Very Often 16

13. In the past 30 days, how often have you gotten angry at people?

O Never

O Seldom

O Sometimes

O Often

O Very Often

14. In the past 30 days, how often have you had to take more of your medication

than prescribed?

O Never

O Seldom

O Sometimes

O Often

O Very Often

15. In the past 30 days, how often have you borrowed pain medication from

someone else?

O Never

O Seldom

O Sometimes

O Often

O Very Often

16. In the past 30 days, how often have you used your pain medication for

symptoms other than for pain (e.g., to help you sleep, improve your mood, or relieve

stress)?

O Never

O Seldom

O Sometimes

O Often

O Very Often 17

1 7. In the past 30 days, how often have you had to visit the Emergency Room?

O Never

O Seldom

O Sometimes

O Often

O Very Often

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