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

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* What is your full address | demographics?

Address

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* Marital Status:

Single

Married

Divorced

Seperated

Widowed

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* What is your race?

Asian

Black

White

Pacific Islander

Native American

Multi

Other (please specify)

None of the above

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* What is your preferred language?

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* What is your sex?

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* Name of Primary Insurance Company

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* First and Last Name of Person Who Carries Insurance Policy

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* Relationship to patient:

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* DOB of Policy Holder

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* Policy Number

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* Group Number

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* Social Security Number of Policy Holder

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* Insured Employer:

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* Insured Employer Phone Number

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* Secondary Insurance Policy Holder (if applicable)

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* Name of Secondary Insurance

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* Social Security Number of Secondary Insurance Holder

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* Date of Birth of Secondary Policy Holder

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* Relationship to Patient

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* Patient's Employer

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* Patient's Employer Phone Number

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* Nearest relative (or friend, not spouse) not living with you

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* Relationship to patient

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* Nearest Relative Phone Number

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* Who Is your Referring Physician?

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* Who referred you to our office?

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* Is your injury Work Related?

Yes

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* Is This Injury Accident Related?

Yes

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* If your injury is MVA (motor vehicle accident) related, have you obtained an accident report?

Yes

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* 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:

MEDICAL HISTORY FORM

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* What is the concern that brings you in today?

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* When did your pain start?

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* Do you experience any numbness or tingling (check all that apply)

None

Arms

Hands

Fingers

Hips

Legs

Feet

Toes

Other

Other (please specify)

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* Do you experience any weakness? If yes, please note location.

Yes

Pain is located (please specify)

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* Does anything make the pain better? (Check all that apply)

Sitting

Walking

Standing

Bending forward/backward

Coughing/Sneezing

Medication

Exercise

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* Does anything make the pain worse? (Check all that apply)

Sitting

Standing

Walking

Bending forward/backward

Coughing/sneezing

Medication

Exercise

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* Describe the pain (Check all that apply)

Sharp

Tender

Aching

Gnawing

Stabbing

Shooting

Continuous

Intermittent

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* Please rate your pain on a scale from 0 - 10

0 -No Pain

5 - Moderate Pain

10 - Worst Pain Possible

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* Are your current medications helpful?

Yes

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* Which physician prescribed your medications last?

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* Have you ever participated in physical therapy for this condition? If yes, when?

Yes

When?

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* What was the date of your injury?

Date / Time

Date

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* When did your symptoms begin?

Date / Time

Date

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* Is this condition related to (check any that apply)

Work

Motor Vehicle Accident

Sports Injury

None

Other (please specify)

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* 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.

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* How did the injury happen? Please include details on where and what time it happened.

Review Of Symptoms

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* Are You Experiencing Any Of The Following Symptoms?

General:Chills

General: Excessive Weight Gain/Loss

General: Fever

General: Night Sweats

Skin: Rash

HEENT: Hearing Problems

HEENT: Visual Problems

Respiratory: Cough

Respiratory: Shortness Of Breath

Cardiovascular: Chest Pain

Gastrointestinal: Constipation

Gastrointestinal: Diarrhea

Gastrointestinal: Difficulty Swallowing

Gastrointestinal: Nausea

Gastrointestinal: Stomach Pain

Gastrointestinal: Vomiting

Genitourinary: Sexual Problems

Genitourinary: Urinary Difficulty

Musculoskeletal: Joint Swelling

Musculoskeletal: Swollen arms/legs

Neurological: Dizziness

Neurological: Headaches

Psychiatric: Alcohlism

Psychiatric: Depression

Psychiatric: Substance Abuse

Hematology: Swollen Lymphadenopathy

Other (please specify)

None of the above

PAST MEDICAL HISTORY

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* Check All That Apply To You. Past Medical History Of:

Asthma

Abnormal EKG

Arthritis

Back Trouble

Bleeding Disorder

Blood Disease (Anemia, etc)

Cancer

Diabetes

Emphysema/Other Lung Problems

Epilepsy or Seizures

Facial Bone Fractures

Glaucoma

Heart Attack

Heart Disease

Hepatitis

High Blood Pressure

High Cholesterol

Jaundice

Kidney Disease

Mono

Muscle Weakness

Neck Trouble

Paralysis

Positive HIV/AIDS test

Stroke

Thyroid DIsease

Ulcers

Other (please specify)

None of the above

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* Have you ever used Tobacco products?

Currently

Past Use

Never

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* If yes, above -- please check items used/using

Cigarettes

Smokeless Tobacco

Cigars

How many per week?

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* Alcohol Use:

Yes

If yes, how many drinks per week?

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* What is your occupation?

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* How many children or dependents at home?

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* Have any of your family members has any of the following problems?

	Father	Mother	Sibling	Other
Arthritis	Arthritis Father	Arthritis Mother	Arthritis Sibling	Arthritis Other
Cancer	Cancer Father	Cancer Mother	Cancer Sibling	Cancer Other
Diabetes	Diabetes Father	Diabetes Mother	Diabetes Sibling	Diabetes Other
High Blood Pressure	High Blood Pressure Father	High Blood Pressure Mother	High Blood Pressure Sibling	High Blood Pressure Other
Kidney Disease	Kidney Disease Father	Kidney Disease Mother	Kidney Disease Sibling	Kidney Disease Other
Liver Disease	Liver Disease Father	Liver Disease Mother	Liver Disease Sibling	Liver Disease Other
Lung DIsease	Lung DIsease Father	Lung DIsease Mother	Lung DIsease Sibling	Lung DIsease Other
Mental Illness	Mental Illness Father	Mental Illness Mother	Mental Illness Sibling	Mental Illness Other
Muscle DIsease	Muscle DIsease Father	Muscle DIsease Mother	Muscle DIsease Sibling	Muscle DIsease Other

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* List ALL ALLERGIES to any medications and the reactions. If none, please write none.

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* Please include all current medications, even over the counter and supplements. If none, please write NONE

Drug Number 1 Name, Dose and Frequency:

Drug Number 2 Name, Dose and Frequency:

Drug Number 3 Name, Dose and Frequency:

Drug Number 4 Name, Dose and Frequency:

Drug Number 5 Name, Dose and Frequency:

Drug Number 6 Name, Dose and Frequency:

Drug Number 7 Name, Dose and Frequency:

Drug Number 8 Name, Dose and Frequency:

Drug Number 9 Name, Dose and Frequency:

Drug Number 10 Name, Dose and Frequency:

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* List all surgeries you have had and year you had the surgery. If you have had no surgeries, please write NONE

Surgery 1 & Year:

Surgery 2 & Year:

Surgery 3 & Year:

Surgery 4 & Year:

Surgery 5 & Year:

Surgery 6 & Year:

Surgery 7 & Year:

Surgery 8 & Year:

Surgery 9 & Year:

Surgery 10 & Year:

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* Have You Had Any Orthopedic Complaints Resulting In Radiologic Procedures In The Last Year?

Radiology Procedure & Year:

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* 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).

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* Are you presently involved in a accident, MVA or medical lawsuit? If yes, please indicated body part involved below.

Yes

Body Part (please specify)

None of the above

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* Have you been treated before for this injury?

Yes

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* If yes, were X-rays or tests done?

Yes

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* If yes, will you bring them or a report with you?

Yes

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* If yes, are you able to continue with activity or work?

Yes

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

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* What is your full legal name?

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* What is your date of birth?

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* What is your full address | demographics?

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* Marital Status:

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* What is your race?

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* What is your preferred language?

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* What is your sex?

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* Name of Primary Insurance Company

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* First and Last Name of Person Who Carries Insurance Policy

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* Relationship to patient:

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* DOB of Policy Holder

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* Policy Number

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* Group Number

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* Social Security Number of Policy Holder

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* Insured Employer:

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* Insured Employer Phone Number

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* Secondary Insurance Policy Holder (if applicable)

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* Name of Secondary Insurance

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* Social Security Number of Secondary Insurance Holder

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* Date of Birth of Secondary Policy Holder

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* Relationship to Patient

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* Patient's Employer

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* Patient's Employer Phone Number

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* Nearest relative (or friend, not spouse) not living with you

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* Relationship to patient

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* Nearest Relative Phone Number

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* Who Is your Referring Physician?

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* Who referred you to our office?

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* Is your injury Work Related?

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* Is This Injury Accident Related?

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* If your injury is MVA (motor vehicle accident) related, have you obtained an accident report?

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* What is the concern that brings you in today?

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* When did your pain start?

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* Do you experience any numbness or tingling (check all that apply)

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* Do you experience any weakness? If yes, please note location.

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* Does anything make the pain better? (Check all that apply)

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* Does anything make the pain worse? (Check all that apply)

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* Describe the pain (Check all that apply)

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* Please rate your pain on a scale from 0 - 10