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NEW PATIENT INFORMATION FORM

Please print all information. All blanks must be filled to allow us to serve you quickly and efficiently.

Thank you for your cooperation.

Date:

Date of Birth:

Patient Name:

Address:

Phone: Home: (

)

Work: (

)

How were you referred to The Emory Spine Center:  Physician

 Patient / Friend

 Health Connection

 Workers Comp

 Emory Reputation  Insurance

 Radio / TV Advertisement

 Other:

Referring Physician or Referral Source:

Address:

City:

Phone: (

)

Fax: (

)

Do you want your medical records sent to this physician?

 Yes

 No

Primary Doctor:

Address:

City:

Phone: (	)			Fax: (	)
Do you want your medical records sent to this physician?				 Yes	 No

Are there any other physicians to whom you would like your medical records sent? (Please include name and address)

(Continued on next page)

SpineIntake.doc 3/20/04

Page 2

ORTHO PAIN CHART

Mark the areas on your body where you feel the described sensations using the appropriate symbol from the list below. Please include all affected areas.

	= = =		o o o	Burning	x x x		/ / / /
Numbness =	= = =	Pin & Needles =	o o o	Aching =	x x x	Stabbing =	/ / / /
	= = =		o o o		x x x		/ / / /

RL LR

Please indicate your current pain level by placing a line below with “0” = no pain and “10” = worst pain imaginable.

Example: Pain

Pain at its Worst

Pain at its Best
(lying down, resting)	0
	0
Pain on Average
Pain on Average

		0

SpineIntake.doc 3/20/04

Page 3

HISTORY OF PRESENT COMPLAINT

Age:

2.  Male

 Female

3.  Right Handed

 Left Handed

Where is your problem located?

 Left side  Right side

 Neck

 Upper Back

 Arm/Elbow

 Shoulder

 Wrist/Hand

 Lower Back

 Hip

 Leg

 Knee

 Ankle

 Foot

How long have you had this problem?

Since?

month

day

year

6. Briefly, please give the details of how this problem originally started:

7.Was this from a work-related injury?  No  Yes Have you missed any work because of this problem?

- Is it under workers compensation  No  Yes  No  Yes, how much?

8.Please describe your present pain now (what you feel, where, when, etc.):

9.Of the following list of treatments, please indicate the effect of those which have been used in an attempt to help

your present problem: (Check one of each)

	Which type	Helpful	No Help	Not Used
Antiinflammatory				
Muscle Relaxants				
Narcotic Pain Medications				
Hot Packs				
Ice				
Ultrasound				
Physical Therapy Treatment				
Cortisone Injection				
Trigger Point Injection				
Brace/Splint				
Chiropractor				
Acupuncture				
Other:				
	(Continued on next page)

SpineIntake.doc 3/20/04

Page 4

PAST HISTORY

10.

Please indicate whether you have had any of the following studies for this problem:

YES

WHEN/WHERE

YES NO

WHEN/WHERE

Regular X-ray



CT Scan



EMG



MRI



11.

Have you had surgery for this problem in the past: (Check one)  Yes  No

How many times?

What was the date(s) of the most recent surgery?

Did you improve from the surgery procedure(s)?

 Yes

 No

12.

Have you had any past episodes of similar pain or injury?

 Yes

 No

(please describe)

SOCIAL HISTORY

13.

Current work status:  Working full duty

 Working restricted duty (Since

)

 Retired

 Disabled

( Since

)  Student

 Homemaker

 Unemployed

Company:

Occupation:

Title:

How long have you worked for this company?

14.

Marital status

 Single

 Married

 Divorced

 Widowed

15.

Number of Children:

16.

I live:

 Alone

 With:

17.

I live in a:

 House

 Apartment

 Assisted living

 Nursing home

18.

Are you a cigarette smoker?

 Yes, now  Never  Quit -

How long ago did you quit?

If you answered “yes” or “quit”, how much do or did you smoke per day?

 Less than ½ pack

 ½ pack

 ¾ pack

 1 pack

 More (How many?)

How old were you when you started smoking?

 None

19.

Do you drink any alcoholic beverages?

(Check one)

 0 to 3 drinks per month

 1 to 2 drinks per day

 3 to 5 drinks per day

 More than 5 drinks per day.

How many?

Alcoholic in past?

 Yes

 No

20.

Have you ever had a problem with drug dependence?

 Yes

 No

21.

Are there any law suits pending or contemplated related to your problem?

 Yes

 No

If yes, please give your attorney’s name and phone number:

SpineIntake.doc 3/20/04

							Page 5

	MEDICAL/SURGICAL HISTORY
	Please choose all current and past medical conditions
 No medical problem		 Diabetes			 Bleeding disorders
 High blood pressure		 Thyroid disease			 Anemia
 Heart attack		 Stomach ulcers /  Gastric Reflux			 Blood clots in legs/lung
 Heart failure		 Irritable bowel			 Endometriosis
 Abnormal heart rhythm		 Stroke			 Ovarian cysts
 Lung disease		 Seizures			 Anxiety
 Tuberculosis		 Cancer – where?			 Depression
 Asthma		 Kidney Failure			 Schizophrenia
 Bronchitis		 Kidney Stones			 Anorexia/bulemia
 Emphysema		 Osteoporosis			 Alcoholism
 Liver disease		 Osteoarthritis			 Seen a psychiatrist
 Hepatitis		 Rheumatoid arthritis			 HIV
Are you under a doctor’s care for any other medical condition?			 Yes	 No		If yes, please explain

	Please choose all surgeries you have had
 Spine-Neck		 Appendix /  Intestine			 Eyes
 Spine-Lower back		 Hernia /  Colon /  Rectum			 Ears
 Brain		 Hysterectomy /  C-section /  Female			 Nose
 Heart /  Pacemaker /  IV Filter		 Kidneys /  Bladder /  Urinary			 Throat /  Tonsils
 Angioplasty /  Stent		 Prostate			 Other
 Lung		 Shoulders /  Arms /  Hands		> Describe

 Gallbladder /  Stomach		 Hips /  Knees /  Legs /  Feet > Describe

List All Allergies

Substance		Reaction

List All Current Medications

Name		Dose

(Continued on next page)

SpineIntake.doc 3/20/04

Page 6

FAMILY HISTORY

What illnesses run in your close family (other than yourself)?

 Scoliosis	 Diabetes	 Kidney disease
 Spine disease	 Cancer	 Other:
 Arthritis	 Bleeding disorder
 Heart disease	 Mental illness
 High blood pressure	 Alcoholism

REVIEW OF SYSTEMS

Please check off any current or recent problems you have

GENERAL

Unexplained weight loss

Appetite change

Fevers or chills

Night sweats

Marked fatigue

Difficulty sleeping

EAR, NOSE, THROAT

Difficulty swallowing

Hoarseness

Loss of hearing

Ear pain

Nosebleeds

Gum trouble

EYES

Glasses

Change of vision

CARDIOVASCULAR

Heart or chest pain

Abnormal heartbeat

Poor heart function

Ankle Swelling

LUNG

Morning cough

Shortness of breath

Productive cough or sputum

DIGESTIVE

Nausea or vomiting

Stomach pain or ulcers

Heartburn/acid stomach

Frequent diarrhea

Frequent constipation

Uncontrolled loss of stool

Blood in stool

Hemorrhoids

SKIN

Frequent rashes

Frequent itchiness

Easy bruising

Swollen ankles

NEUROLOGICAL

Seizures

Blackouts/fainting

Tremor

Headaches/migraines

MUSCULOSKELETAL

Joint Pains

Joint Swelling

Back Pain

Neck Pain

Muscle Aches

GENITOURINARY

Burning on urination

Difficulty starting urination

Incontinence

Pelvic pain

Urinate at night more than once

Unable to completely empty bladder

PSYCHIATRIC

Depression

Nervous exhaustion

Anxiety

Paranoia

Obsessive/compulsive behavior

SpineIntake.doc 3/20/04

Question	Answer
Form Name	Emory Healthcare New Patient Form
Form Length	6 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 30 sec
Other names	emory patient form, emory new patient forms, emory neurology new patient forms, emory healthcare new patient

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