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Please hit done if you're finished to submit your new patient paperwork to our team!

What is your full legal name? (Required.)
What is your date of birth?(Required.)
Date / Time
What is your full address | demographics?(Required.)
Marital Status:(Required.)
What is your race?
What is your preferred language?
What is your sex?(Required.)
Name of Primary Insurance Company(Required.)
First and Last Name of Person Who Carries Insurance Policy(Required.)
Relationship to patient:(Required.)
DOB of Policy Holder(Required.)
Policy Number(Required.)
Group Number
Social Security Number of Policy Holder(Required.)
Insured Employer:
Insured Employer Phone Number
Secondary Insurance Policy Holder (if applicable)
Name of Secondary Insurance
Social Security Number of Secondary Insurance Holder
Date of Birth of Secondary Policy Holder
Relationship to Patient
Patient's Employer(Required.)
Patient's Employer Phone Number
Nearest relative (or friend, not spouse) not living with you(Required.)
Relationship to patient(Required.)
Nearest Relative Phone Number(Required.)
Who Is your Referring Physician?
Who referred you to our office? 
Is your injury Work Related?(Required.)
Is This Injury Accident Related?(Required.)
If your injury is MVA (motor vehicle accident) related, have you obtained an accident report? (Required.)
I hereby authorize insurance benefits to be paid directly to the facility and the physician and I am financially responsible for non-covered services. I also authorize the physician to release my information in the process of filing claims. I acknowledge and agree that I have received a copy of the TPG privacy practices.  Please type your name in agreement:(Required.)
MEDICAL HISTORY FORM
What is the concern that brings you in today?(Required.)
When did your pain start?(Required.)
Do you experience any numbness or tingling (check all that apply)(Required.)
Do you experience any weakness? If yes, please note location.(Required.)
Does anything make the pain better? (Check all that apply)(Required.)
Does anything make the pain worse? (Check all that apply)(Required.)
Describe the pain (Check all that apply)(Required.)
Please rate your pain on a scale from 0 - 10(Required.)
Are your current medications helpful?(Required.)
Which physician prescribed your medications last?
Have you ever participated in physical therapy for this condition? If yes, when?(Required.)
What was the date of your injury? 
Date / Time
When did your symptoms begin? 
Date / Time
Is this condition related to (check any that apply)
If you are seeing us due to a Workers Comp Injury, do you have a Case Manager assigned to your case? If yes, please provide thier name and phone number. 
How did the injury happen? Please include details on where and what time it happened. 
Review Of Symptoms
Are You Experiencing Any Of The Following Symptoms?(Required.)
PAST MEDICAL HISTORY
Check All That Apply To You. Past Medical History Of:(Required.)
SOCIAL HISTORY
Have you ever used Tobacco products?(Required.)
If yes, above -- please check items used/using(Required.)
Alcohol Use:(Required.)
What is your occupation?(Required.)
How many children or dependents at home?(Required.)
FAMILY HISTORY
Have any of your family members has any of the following problems?(Required.)
Father
Mother
Sibling
Other
Arthritis
Cancer
Diabetes
High Blood Pressure
Kidney Disease
Liver Disease
Lung DIsease
Mental Illness
Muscle DIsease
List ALL ALLERGIES to any medications and the reactions. If none, please write none.(Required.)
Please include all current medications, even over the counter and supplements. If none, please write NONE(Required.)
List all surgeries you have had and year you had the surgery. If you have had no surgeries, please write NONE(Required.)
Have You Had Any Orthopedic Complaints Resulting In Radiologic Procedures In The Last Year?
Effective January 1, 2020. All controlled substances must be electronically sent to your pharmacy. What Is Your Preferred Pharmacy? (Please make sure to include name, phone number and location).(Required.)
Are you presently involved in a accident, MVA or medical lawsuit? If yes, please indicated body part involved below.(Required.)
Have you been treated before for this injury? (Required.)
If yes, were X-rays or tests done?(Required.)
If yes, will you bring them or a report with you? 
If yes, are you able to continue with activity or work? 
If yes, what is the location of the pain?
If yes, what diagnosis was given? 
If yes, what treatment was given?
If surgery was performed, please obtain a copy of the operative report for our records. What was the date and surgery performed?
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