Injury New Patient Paperwork

ID
Appointment Date
Calendar Resource
Appointment Type
Appointment Type
Patient's Name
Injury New Patient Paperwork:
Patient Information:
Patient Name*

First NameLast Name
Date of Birth: *

MonthDayYear
Preferred Language*
Sex*

MaleFemaleOther
SSN
Employment:
Employer:
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number:*
Email Address:*
example@example.com

Emergency Contact:
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Emergency Contact Relationship*
Do you have Health Insurance?*

YesNo

Insurance Information:

Primary Insurance
Insurance Card Front Image:

Browse Files

Cancelof
Insurance Card Back Image:

Browse Files

Cancelof
Primary Insurance Payer Name
Primary Insurance Insured's ID Number
Primary Insurance Group Number
Primary Insurance Subscriber’s Name
Primary Insurance Subscriber's Date of Birth
Primary Insurance Relationship to Subscriber

SelfSpouseChildOther
Do you have Secondary Insurance?

YesNo

Insurance Information

Secondary Insurance
Insurance Card Front:

Browse Files

Cancelof
Insurance Card Back:

Browse Files

Cancelof
Secondary Insurance Payer Name
Secondary Insurance Insured's ID Number
Secondary Insurance Group Number
Secondary Insurance Subscriber’s Name
Secondary Insurance Subscriber's Date of Birth
Secondary Insurance Relationship to Subscriber

SelfSpouseChildOther

Did another provider refer you to our office?*

YesNo

Referring Provider
Referring Provider*

First NameLast NameSuffix
Referring Provider Phone Number*

Do you have a Primary Care Provider?

Primary Care Provider:
Primary Care Provider Name*

First NameLast NameSuffix
Primary Care Provider Phone Number*
Date of Last Office Visit*

Injury Details:
Please select type of injury:

Auto AccidentWork RelatedOther

Claim Information

Please only fill out which is relevant to your situation

For Worker's Comp Claim:

	Please fill out all information below:
Insurance Name
State
Body Region
Claim #
Adjustor Name
Phone #
Fax #
Email
Address

For Attorney Lien:

	Please fill out all information below:
Attorney Office
State
Body Region
Attorney
Paralegal
Phone #
Fax #
Email
Address

For Well States:

	Please fill out all information below:
Claim #
Case Manager
Contact
Body Region

For Micare

	Please fill out all information below:
Case Manager
Contact
Body Region
Email

Allergies:

Please specify the reaction to allergy
Allergies*

NoneContrast DyeIodineLatexPenicillinSulfaVersedFentanylOther
Please specify reaction to all allergies that you have:
Medications:

Please list medication, dose, and frequency
Current prescriptions (include all Rx's)*
Please type "none" if you are not currently taking any medications
Are you taking any blood thinners? If Yes, please list*
*Otherwise type "none"
Previously tried pain medication (please list the reason it was discontinued)*
*Otherwise type "none"

Refill of Medications:
Please list any of your PAIN MANAGEMENT related medications you would like refilled or renewed at your visit today (Please also include your pharmacy). Otherwise, skip.

Are you 65+ years?*

YesNo

Health & Wellness Questionnaire:

Answering the following screening “Health and Wellness Questionnaire” will help us understand your needs in multiple areas of your life and how we can best help you to be well. Participation is voluntary.
Do you wish to participate in the questionnaire?*

YesNo

Health and Wellness Questionnaire

At Southwest Spine and Pain Center, we believe in providing the best care possible. Answering the following questions will help us understand your needs in multiple areas of your life and how we can best help you to be well. Participation is voluntary. You are free to stop at any time, or to leave questions blank if you would prefer not to answer them. However, the more information we have, the better able we are to provide quality care.
1. In general, would you say your health is:
2. In general, please rate how well you carry out your usual social activities and roles. (This includes activities at home, at work and in your community, and responsibilities as a parent, child, spouse, employee, friend, etc.)
3. In general, how would you rate your physical health?
4. To what extent are you able to carry out your everyday physical activities such as walking, climbing stairs, carrying groceries, or moving a chair?
5. How would you rate your fatigue on average?
6. How would you rate your pain on average?
7. In general, would you say your quality of life is:
8. In general, how would you rate your mental health, including your mood and your ability to think?
9. How often have you been bothered by emotional problems such as feeling anxious, depressed, or irritable?
10. In general, how would you rate your satisfaction with your social activities and relationships?
11. In the past 7 days, my sleep quality was:
12. In general, would you say your nutrition is:
13. In general, would you say your fitness is:
Over the last 2 weeks, how often have you been bothered by any of the following problems?
14. Feeling nervous, anxious or on edge.
15. Not being able to stop or control worrying.
16. Little interest or pleasure in doing things.
17. Feeling down, depressed, or hopeless.
18. Are past or present experiences with any of the following impacting you in your life in a negative way?
Abuse
Violence (e.g., domestic, work, military)
Military service or combat
Unexpected death of a family member or friend (i.e. suicide, accidents, etc)
19. Please answer these questions based on the last 12 months. These questions refer to use of alcohol, illegal drugs, prescription drugs not prescribed to you, or misuse of your prescriptions. Do not check “yes” in reference to taking your prescription medications as prescribed by your doctor.
Have you felt you ought to cut down on your drinking or drug use?
Have people annoyed you by criticizing your drinking or drug use?
Have you felt bad or guilty about your drinking or drug use?
Have you ever had a drink or used drugs first thing in the morning to steady your nerves or get rid of a hangover?

Please click "SUBMIT" if you are ready to submit.
Should be Empty:

	Yes	No
Were you transferred by ambulance to the ER following the accident?
Consciousness lost?
Seatbelt worn?
Prior pain in the same body region?

	Date the imaging was done:	Location the Imaging was done: (City/State)	Name of the Facility where Imaging was done:
X-ray
MRI
CT Scan
EMG
Bone Scan

	Relief	Duration	Name of Doctor	Name of Facility	Date of Procedure	Level of procedure: (Ex- L5-S1)
Basivertebral Nerve Ablation
Epidural Injection
Facet Injection
Hip Injection
Kyphoplasty
Peripheral Nerve Stimulator
Radiofrequency Ablation
SI Joint Fusion
SI Joint Injection
Spinal Cord Stimulator
Vertiflex

	What type of surgery was performed in this spine region?	Levels of Surgery: (if known. Ex: L5-S1)	Date of the Surgery:	Name of the Surgeon who performed the surgery (if unsure, type "unknown"):	Name of the Facility where surgery was performed:
Cervicothoracic Spine Surgery
Lumbosacral Spine Surgery
Scoliosis Surgery

	What type of surgery was performed in this spine region?	Levels of Surgery: (if known. Ex: L5-S1)	Date of the Surgery:	Name of the Surgeon who performed the surgery (if unsure, type "unknown"):	Relief of Surgery (0-100% relief how much did it help? 100% = cured the issue)	Duration of relief from the Surgery (Ex: * days, * months, *years)
Cervicothoracic Spine Surgery #2
Lumbosacral Spine Surgery #2
Scoliosis Surgery #2
Unknown Type Spine Surgery #2

Injury New Patient Paperwork:

Patient Information:

Emergency Contact:

Insurance Information:

Insurance Information

Referring Provider

Primary Care Provider:

Financial & Release of Information Forms:

Please read and sign:

Authorization to release or use information for treatment, payment, or healthcare options:

I agree and consent to releasing information to me in the following manners:

Permission to release to the following individuals:

FINANCIAL AGREEMENT:

Clinical Patient Information:

Injury Details:

Auto Accident Details:

Claim Information

Allergies:

Medications:

Past Medical History:

Social History:

Surgical History:

Refill of Medications:

Falls Risk Assessment:

Health & Wellness Questionnaire:

Health and Wellness Questionnaire

	What type of surgery was performed in this spine region?	Levels of Surgery: (if known. Ex: L5-S1)	Date of the surgery:	Name of the Surgeon who performed the surgery (if unsure, type "unknown"):	Relief of Surgery (0-100% relief how much did it help? 100% = cured the issue)	Duration of relief from the Surgery (Ex: * days, * months, * years)
Cervicothoracic Spine Surgery #3
Lumbosacral Spine Surgery #3
Scoliosis Surgery #3
Unknown Type Spine Surgery #3

	Yes	No
Have you had a fall in the last year?
Do you feel unsteady when walking or standing?
Do you have trouble remembering, learning new things or concentrating?
Do you get lightheaded or dizzy when transitioning from lying down to standing?
Do you have to walk around holding onto furniture when you walk through a room?
Do you need support when getting in and out of the tub or up from the toilet?

	1	2	3	4	5	6	7	8+
Beer
Wine
Hard Liquor

	Never Used	Former User	Current SOME day User	1-9 daily (light)	10+ daily (heavy)
Cigarettes
Cigars
Pipe
Chewing Tobacco
Dipping Tobacco
Vape Pen