New Patient Intake Form - LV Pain Center

Please use the online form for LV Pain Center
* = Required Information

1Patient and Details > 2Submission Page > 3Review Your Entry
PATIENT INFORMATION
Name Name * First Last
Date of Birth: Date of Birth: * / MM / DD YYYY
Age *
Must be between 1 and 3 digits. Currently Entered: 0 digits.
Sex *

Sex Male Female Intersex Prefer not to say Another term (please specify) Another term (please specify)
Address Address *
Street Address
Address Line 2 City State / Province / Region Postal / Zip Code Country
Marital Status
Primary Phone # Primary Phone # * - ### - ### ####
Work Phone # Work Phone # - ### - ### ####
Secondary Phone # Secondary Phone # - ### - ### ####
Best time to call? *
Email *
Employment *

Employment Full Time Part Time Retired Student None
Employer *
How did you hear about us? *
Referring Physician Name
Primary Care Physician
How did you hear about us?
(Other)
EMERGENCY CONTACT INFORMATION
Emergency Contact Name Emergency Contact Name First Last
Emergency Contact Cell Phone # Emergency Contact Cell Phone # - ### - ### ####
Emergency Contact Home Phone # Emergency Contact Home Phone # - ### - ### ####
Relationship
INSURANCE INFORMATION
Payment Options *

Payment Options Self-pay patient / Health Insurance Attorney lien
Do you have health insurance? *

Do you have health insurance? Yes No
Attach a picture of your Drivers License / ID Card:
Upload a File

Attach Files
Attach a picture of your Health Insurance Card:
(Front Of Card)
Upload a File

Attach Files
Attach a picture of your Health Insurance Card:
(Back Of Card)
Upload a File

Attach Files
Primary Insurance
Copay
Certificate#/Policy ID
Group Number
Subscriber Name
Subscriber DOB Subscriber DOB / MM / DD YYYY
Relationship to Subscriber
Please choose the best option listed that describes your race. *
Race
(Other)
Please choose the best option listed that describes your ethnicity.
Primary Language
Please mark the correct box if the question applies to you, and select the score based upon your gender. If not applicable, please choose N/A.
1. Has anyone in your family ever had a history of substance abuse? *

1. Has anyone in your family ever had a history of substance abuse? Alcohol Illegal Drugs Prescription Drugs N/A
Female Score
(Alcohol)

Female Score
(Alcohol) 1 2 4
Female Score
(Illegal Drugs)

Female Score
(Illegal Drugs) 1 2 4
Female Score
(Prescription Drugs)

Female Score
(Prescription Drugs) 1 2 4
Male Score
(Alcohol)

Male Score
(Alcohol) 3 3 4
Male Score
(Illegal Drugs)

Male Score
(Illegal Drugs) 3 3 4
Male Score
(Prescription Drugs)

Male Score
(Prescription Drugs) 3 3 4
2. Have you ever had a personal history of substance abuse? *

2. Have you ever had a personal history of substance abuse? Alcohol Illegal Drugs Prescription Drugs N/A
Female Score - Personal
(Alcohol)

Female Score - Personal
(Alcohol) 3 4 5
Female Score - Personal
(Illegal Drugs)

Female Score - Personal
(Illegal Drugs) 3 4 5
Female Score - Personal
(Prescription Drugs)

Female Score - Personal
(Prescription Drugs) 3 4 5
Male Score - Personal
(Alcohol)

Male Score - Personal
(Alcohol) 3 4 5
Male Score - Personal
(Illegal Drugs)

Male Score - Personal
(Illegal Drugs) 3 4 5
Male Score - Personal
(Prescription Drugs)

Male Score - Personal
(Prescription Drugs) 3 4 5
3. Mark box if your age is between 16-45 *

3. Mark box if your age is between 16-45 Yes, I am between 16-45 N/A
Female Score 16-45

Female Score 16-45 1
Male Score 16-45

Male Score 16-45 1
4. Have you had a history of preadolescent Sexual Abuse? *

4. Have you had a history of preadolescent Sexual Abuse? Yes, I have had a history of preadolescent Sexual Abuse N/A
Female Score
(Preadolescent Sexual Abuse?)

Female Score
(Preadolescent Sexual Abuse?) 3
Male Score
(Preadolescent Sexual Abuse?)

Male Score
(Preadolescent Sexual Abuse?) 0
5. Have you ever been diagnosed with Attention Deficit Disorder, Obsessive Compulsive Disorder, Bipolar, or Schizophrenia? *

5. Have you ever been diagnosed with Attention Deficit Disorder, Obsessive Compulsive Disorder, Bipolar, or Schizophrenia? Yes, I have been diagnosed N/A
Female Score
(diagnosed)

Female Score
(diagnosed) 2
Male Score
(diagnosed)

Male Score
(diagnosed) 2
6. Have you ever been diagnosed with Depression? *

6. Have you ever been diagnosed with Depression? Yes, I have been diagnosed with Depression N/A
Female Score
(Diagnosed with Depression)

Female Score
(Diagnosed with Depression) 1
Male Score
(Diagnosed with Depression)

Male Score
(Diagnosed with Depression) 1
Total
(Add up all checkboxes above)
EXCLUDING N/A *
Please identify your main pain area(s)
Abdominal Pain
(Select ALL that Apply)

Abdominal Pain
(Select ALL that Apply) Radiates into Pelvis Radiates into Lower back Radiates into Left Leg Radiates into Right Leg
Lower Back Pain
(Select ALL that Apply)

Lower Back Pain
(Select ALL that Apply) Radiates into Left Leg Radiates into Right Leg Buttock Pain Left Side Buttock Pain Right Side
Upper Back Pain
(Select ALL that Apply)

Upper Back Pain
(Select ALL that Apply) Radiates into Ribs - Left Side Radiates into Ribs - Right Side
Neck Pain
(Select ALL that Apply)

Neck Pain
(Select ALL that Apply) Causes headaches Radiates into Arms - Left Side Radiates into Arms - Right Side Radiates into Mid-Back
Upper Body Pain
(Select ALL that Apply)

Upper Body Pain
(Select ALL that Apply) Shoulders - Left Side Shoulders - Right Side Arms - Left Side Arms - Right Side Hands - Left Side Hands - Right Side
Headaches
(Select ALL that Apply)

Headaches
(Select ALL that Apply) Frontal Area - Left Side Frontal Area - Right Side Temples - Left Side Temples - Right Side Back of Head - Left Side Back of Head - Right Side
Lower Body Pain
(Select ALL that Apply)

Lower Body Pain
(Select ALL that Apply) Groin - Left Side Groin - Right Side Pelvis - Left Side Pelvis - Right Side Hips - Left Side Hips - Right Side Buttocks - Left Side Buttocks - Right Side Knees - Left Side Knees - Right Side Feet - Left Side Feet - Right Side
Facial Pain
(Select ALL that Apply)

Facial Pain
(Select ALL that Apply) Facial Pain - Left Side Facial Pain - Right Side
Pelvic Pain
(Select ALL that Apply)

Pelvic Pain
(Select ALL that Apply) Coccyx Radiates into Legs - Left Side Radiates into Legs - Right Side
Diffused Body Pain
(Select ALL that Apply)

Diffused Body Pain
(Select ALL that Apply) Chest Back Neck Arms - Left Side Arms - Right Side Legs - Left Side Legs - Right Side Face Head
Quality of pain

Quality of pain Burning Deep Cramping Shooting Sharp Aching Stabbing Dull Throbbing Pins and Needles
Severity of Pain

Severity of Pain Mild Mild to Moderate Moderate Moderate to Severe Severe
Onset of Pain

Onset of Pain Acute Sudden Gradual Sudden, following incident Gradual, following incident Following trauma Following a vehicle accident
Pain Pattern

Pain Pattern Intermittent Episodic Persistent
Duration of Pain

Duration of Pain Years Months Weeks Other
How Many Years?
How Many Months?
How Many Weeks?
How Long?
(Other)
Course of Pain:
(Select only one)

Course of Pain:
(Select only one) Increasing Rapidly Improving Worsening Constant Gradual Worsening Rapidly Worsening Without Change Recurrent Decreasing Night Pain No Night Pain Gradually Improving
(Pain Levels Intensity EXAMPLE)
Make selections below Examples

Pain Intensity Level - Best
Pain Intensity Level - Best	0	1	2	3	4	5	6	7	8	9	10
Intensity of Pain at it's BEST (SELECT 0-10)	Intensity of Pain at it's BEST (SELECT 0-10)0	Intensity of Pain at it's BEST (SELECT 0-10)1	Intensity of Pain at it's BEST (SELECT 0-10)2	Intensity of Pain at it's BEST (SELECT 0-10)3	Intensity of Pain at it's BEST (SELECT 0-10)4	Intensity of Pain at it's BEST (SELECT 0-10)5	Intensity of Pain at it's BEST (SELECT 0-10)6	Intensity of Pain at it's BEST (SELECT 0-10)7	Intensity of Pain at it's BEST (SELECT 0-10)8	Intensity of Pain at it's BEST (SELECT 0-10)9	Intensity of Pain at it's BEST (SELECT 0-10)10

Pain Intensity Level - Worst
Pain Intensity Level - Worst	0	1	2	3	4	5	6	7	8	9	10
Intensity of Pain at it's WORST (SELECT 0-10)	Intensity of Pain at it's WORST (SELECT 0-10)0	Intensity of Pain at it's WORST (SELECT 0-10)1	Intensity of Pain at it's WORST (SELECT 0-10)2	Intensity of Pain at it's WORST (SELECT 0-10)3	Intensity of Pain at it's WORST (SELECT 0-10)4	Intensity of Pain at it's WORST (SELECT 0-10)5	Intensity of Pain at it's WORST (SELECT 0-10)6	Intensity of Pain at it's WORST (SELECT 0-10)7	Intensity of Pain at it's WORST (SELECT 0-10)8	Intensity of Pain at it's WORST (SELECT 0-10)9	Intensity of Pain at it's WORST (SELECT 0-10)10

Pain Intensity Level - Average
Pain Intensity Level - Average	0	1	2	3	4	5	6	7	8	9	10
Intensity of Pain on AVERAGE (SELECT 0-10)	Intensity of Pain on AVERAGE (SELECT 0-10)0	Intensity of Pain on AVERAGE (SELECT 0-10)1	Intensity of Pain on AVERAGE (SELECT 0-10)2	Intensity of Pain on AVERAGE (SELECT 0-10)3	Intensity of Pain on AVERAGE (SELECT 0-10)4	Intensity of Pain on AVERAGE (SELECT 0-10)5	Intensity of Pain on AVERAGE (SELECT 0-10)6	Intensity of Pain on AVERAGE (SELECT 0-10)7	Intensity of Pain on AVERAGE (SELECT 0-10)8	Intensity of Pain on AVERAGE (SELECT 0-10)9	Intensity of Pain on AVERAGE (SELECT 0-10)10

Pain Aggravated By
(Select ALL that Apply)

Pain Aggravated By
(Select ALL that Apply) Sneezing Coughing Bowel Movements Bending Twisting Lifting Sitting Standing Walking Lying Down None Other Other
Pain Relieved By
(Select ALL that Apply)

Pain Relieved By
(Select ALL that Apply) Rest Change in Position Exercise Pain Medication Heat Ice Sitting Standing Bending Forward Physical Therapy None Other Other
Associated Factors
(Select ALL that Apply)

Associated Factors
(Select ALL that Apply) Abdominal Pain Arthritis Chills Dysuria Fever Flank Pain Hip Pain Incontinence of Stool Urinary Retention Leg Weakness - Left Side Leg Weakness - Right Side History of Malignancy Unintentional weight loss Numbness Tingling
Numbness - Where?
Tingling - Where?
Daily Activities Impaired by Pain
(Select ALL that Apply)

Daily Activities Impaired by Pain
(Select ALL that Apply) Work Sleeping Shopping Leisure Intimacy Dressing Chores Bathing Exercise None
Previous Evaluations
(Select ALL that Apply)

Previous Evaluations
(Select ALL that Apply) Primary Care Urgent Care Emergency Room Chiropractor Rheumatologist Physiatrist Psychologist Pain Management Orthopedic Surgeon Neurologist Neurosurgeon None
Previous Imaging:
Please Select image and of what part of the body image was taken and when.

Previous Imaging:
Please Select image and of what part of the body image was taken and when. Bone Scan EMG X-ray CT MRI
Bone Scan
What part of the body and when was the image taken?
EMG
What part of the body and when was the image taken?
X-ray
What part of the body and when was the image taken?
CT
What part of the body and when was the image taken?
MRI
What part of the body and when was the image taken?
Physical Therapy

Physical Therapy Stretching exercises Strengthening exercises TEN's Unit Massage Heat Ice None Other Other
Dates
(Physical Therapy)
Previous Injections

Previous Injections Hip Injection Facet Injection Epidural Injection Vertebroplasty Kyphoplasty Other Other
Have you had a Previous Spine Surgery? *

Have you had a Previous Spine Surgery? None Yes
Surgery Type
Surgery Date
Surgeon
Previous Pain Medications:
(Please list dose and frequency)
1.) Previous Pain Medications
(Dose and frequency)
2.) Previous Pain Medications
(Dose and frequency)
3.) Previous Pain Medications
(Dose and frequency)
4.) Previous Pain Medications
(Dose and frequency)
5.) Previous Pain Medications
(Dose and frequency)
6.) Previous Pain Medications
(Dose and frequency)
7.) Previous Pain Medications
(Dose and frequency)
8.) Previous Pain Medications
(Dose and frequency)
Accident/Injury
1.) Are you currently involved in litigation regarding your injury?

1.) Are you currently involved in litigation regarding your injury? Yes No
2.) Is your pain a work related injury?

2.) Is your pain a work related injury? Yes No
3.) Is workman's compensation involved?

3.) Is workman's compensation involved? Yes No
4.) Date of Accident/Injury?
Past Medical History:
(Select ALL that Apply)

Past Medical History:
(Select ALL that Apply) Anemia Anxiety Arthritis Asthma Atrial Fibrillation Bipolar Disorder Bleeding Disorder BPH Breast Cancer Bronchitis CHF Clotting Disorder COPD Coronary Artery Disease Depression Emphysema GI Ulcer Heart Attack Hepatitis HIV/AIDS Hypertension Kidney Disease Liver Disease Osteoporosis Other Cancer Prostate Cancer Seizures Shingles Stroke Thyroid Disease Other Other
Allergies
(Select ALL that Apply)

Allergies
(Select ALL that Apply) Shell Fish Sulfa Drugs Seasonal Allergies Contrast Dye Codeine Penicillin Iodine Latex None
Family History:
(Please specify who if applicable)

Family History:
(Please specify who if applicable) Adopted Alzheimer's Cancer Diabetes Heart Disease High Blood Pressure Mental Illness Migraine Osteoporosis Stroke
Family History:
Please specify who is applicable
Adopted
(Please specify)
Alzheimer's
(Please specify)
Cancer
(Please specify)
Diabetes
(Please specify)
Heart Disease
(Please specify)
High Blood Pressure
(Please specify)
Mental Illness
(Please specify)
Migraine
(Please specify)
Osteoporosis
(Please specify)
Stroke
(Please specify)
Social History:
(Please explain if applicable)

Social History:
(Please explain if applicable) History of Drug Abuse Current Drug Abuse
History of Drug Abuse
(Please explain)
Current Drug Abuse
(Please explain)
Current Medications:
1.) Medication
Dose (mg) and frequency
2.) Medication
Dose (mg) and frequency
3.) Medication
Dose (mg) and frequency
4.) Medication
Dose (mg) and frequency
5.) Medication
Dose (mg) and frequency
6.) Medication
Dose (mg) and frequency
7.) Medication
Dose (mg) and frequency
8.) Medication
Dose (mg) and frequency
9.) Medication
Dose (mg) and frequency
10.) Medication
Dose (mg) and frequency
Are you taking blood thinners?

Are you taking blood thinners? Yes No
Past Surgical History
(Select ALL that Apply)

Past Surgical History
(Select ALL that Apply) Adenoidectomy Appendectomy Back Surgery - Cervical Back Surgery - Lumbar Back Surgery - Thoracic Brain Surgery CABG Carpal Tunnel - Left Side Carpal Tunnel - Right Side Cataract Surgery Cervical Coronary artery dilation Detached retina repair Gallbladder Hemorrhoidectomy Hernia repair Hip Replacement - Left Side Hip Replacement - Right Side Hysterectomy Knee Arthroscopy Knee Replace - Left Side Knee Replace - Right Side Large Bowel res. Lumbar Lumpectomy Mastectomy Pacemaker Plastic surgery Prostate surgery Shoulder surgery - Left Side Shoulder surgery - Right Side Small Bowel res. Thoracic Thyroidectomy Tonsillectomy Tubal Ligation Vasectomy
Review of Systems
Please mark ALL that are present
General

General Appetite Loss Dietary changes Fatigue Weight Gain > / + 10lbs Weight Gain < / - 10lbs
Skin

Skin Brittle Nails Bruising Open Wound Excessive Sweating Itching Rash Ulcer
HEENT

HEENT Blurred Vision Double Vision Glaucoma Headache Hearing Loss Seasonal Allergies Sleep Apnea Vertigo Visual Loss
Endocrine

Endocrine Appetite Changes Thyroid Problems
Neck

Neck Neck Mass Neck Pain Swollen Glands
Respiratory

Respiratory Chronic Cough Difficulty Breathing Shortness of Breath Stop breathing in Sleep
Cardiovascular

Cardiovascular Chest Pain Difficult to breath lying down Edema Heart Stent Irregular Heart Irregular Heart beat Leg Pain Leg Swelling Rapid Heart beat
Gastrointestinal

Gastrointestinal Abdominal pain Black tarry stool Bloody Stool Constipation Diarrhea Incontinence of stool Nausea Vomiting
Hematology

Hematology Blood clots Easy bruising Nose bleeds Spontaneous bleeding
Musculoskeletal

Musculoskeletal Back Pain Joint Pain Leg Cramps Muscle Atrophy Muscle Weakness Muscle Spasms
Neurological

Neurological Difficulty Speaking Headaches Incontinence - Stool Incontinence - Urine Leg Weakness Numbness Seizures Stroke Trouble Walking
Psychiatric

Psychiatric Anger Anxiety Depression Hallucinations Hearing Voices Mood changes Panic Attacks
Thank you for your time!!
Please click / tap continue to review and submit your completed info.
Date
(Auto Filled) Date
(Auto Filled) / MM / DD YYYY
Save my progress and resume later
Enter Your Email Address *

A special link to resume the form will be sent to your email address.

New Patient Intake Form - LV Pain Center

New Patient Intake Form - LV Pain Center

PATIENT INFORMATION

EMERGENCY CONTACT INFORMATION

INSURANCE INFORMATION

Please mark the correct box if the question applies to you, and select the score based upon your gender. If not applicable, please choose N/A.

Please identify your main pain area(s)

(Pain Levels Intensity EXAMPLE)

Make selections below Examples

Previous Pain Medications: (Please list dose and frequency)

Accident/Injury

Family History: Please specify who is applicable

Current Medications:

Review of Systems Please mark ALL that are present

Thank you for your time!! Please click / tap continue to review and submit your completed info.

Previous Pain Medications:
(Please list dose and frequency)

Family History:
Please specify who is applicable

Review of Systems
Please mark ALL that are present

Thank you for your time!!
Please click / tap continue to review and submit your completed info.