NEUROSPINE SOLUTIONS
New Patient Packet

 

PATIENT INFO
Patient Name:
Social Security #
Birth Date	Male/Female
Address
City, State, Zip
Home Phone
Cell Phone
EMERGENCY CONTACT INFO
Emergency Contact (outside home
Contact Phone
Relationship to patient
EMPLOYMENT
Employment Status
Occupation
How Long?
Employer Name
Employer Address
Employer Phone
SPOUSE INFO -- OR GUARDIAN (if patient is a minor)
Spouse or Guardian
Social Security #
Birth Date
Spouse or Guardian Employer
Employer Address
Employer Phone
FAMILY AND REFERRAL PHYSICIAN INFO
Referring Physician
Complete Address
Phone
Family Physician
Address
Phone
PHARMACY INFO
Pharmacy Name
Address
Phone
INSURANCE INFO
Primary Insurance Co.
Name of Insured and Birth Date
Relationship to patient
Policy Number
Group Number
Employer

NO SHOW POLICY: Effective 7/1/06 there will be a $20.00 No-Show/ Late Cancellation Fee.
Appointments must be cancelled by 3:00 PM of the previous day or by 3: PM on Friday for a Monday appointment. The patient/guardian will be responsible for this fee. It will not be billed to your insurance company.

 

Is your illness/injury due to a work-related incident? If so, please answer the questions below.

Accident Location
Date of Injury
Date Last Worked
How were you injured?
Work Comp Carrier
Carrier Address
Carrier Phone #
Attorney
Attorney Address
Attorney Phone #

 

Is your illness/injury due to an automobile accident? If so, please answer the questions below.

Date of Accident
Accident Location
Fault of Another Party	Y /N
Insurance Carrier
Name of Insured
Policy Number
Claim Number
Attorney
Attorney Address
Attorney Phone #

 

SURGICAL HISTORY

	Yes	No	When		Yes	No	When
Tonsils				Uterus Removed
Appendix				Bladder Surgery
Brain Surgery				Kidney Surgery
Neck Artery Surgery				Hemorrhoids
Eye Surgery				Blood Vessel Surgery
Lung Surgery				Hip Surgery
Heart Surgery				Leg/Arm Surgery
Gallbladder				Disc Rupture (Neck)
Colon Surgery				Disc Rupture (Back)
Prostate				Hernia Repair
Tubal Ligation				Other:

Do You CURRENTLY Have Any of the Following Medical Conditions?

	YES	NO		YES	NO
Heart Disease			Kidney Stones
Lung Disease			Prostate Problems
Thyroid Disease			Kidney Disease
Liver Disease			Weight Loss
Stomach Ulcers			Weight Gain
Cancer			Poor Appetite
Seizures			Serious Illness
Stroke			Psychiatric Care
Diabetes			Irritable Bowel
High Blood Pressure			Gout
Headaches/Migraines			Wear Glasses/Contacts
Anemia			Bleeding Disorders
Painful Joints			Other:

In the PAST have you had any of the following medical conditions?

	YES	NO		YES	NO
Heart Disease			Kidney Stones
Lung Disease			Prostate Problems
Thyroid Disease			Kidney Disease
Liver Disease			Weight Loss
Stomach Ulcers			Weight Gain
Cancer			Poor Appetite
Seizures			Serious Illness
Stroke			Psychiatric Care
Diabetes			Irritable Bowel
High Blood Pressure			Gout
Headaches/Migraines			Wear Glasses/Contacts
Anemia			Bleeding Disorders
Painful Joints			Kidney Stones
Heart Disease			Other:

PATIENT HISTORY

Please list all of the medications that you are currently taking:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

ALLERGIES:
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Are you:
Left Handed ______
Right Handed ______

Height ______
Weight ______
BP __________

SOCIAL HISTORY

Do you smoke? _________ If so, packs per day: ________________
Do you drink alcoholic beverages? Yes______ No______
Do you use recreational drugs? Yes______ No______
Have you ever had a blood transfusion? Yes______ No______
Do you now or have you ever had any know HIV risks? Yes______ No______
Are you: Single______ Married______ Separated______ Divorced______ Widowed______
Number of living children______

FAMILY HISTORY

	Alive	Deceased	Age at Death	Known Medical Problems
Mother
Father
Brothers/Sisters

Treatment for My Current Medical Problems Has Included:

Plain X-Rays		Hot/Cold Packs		Limiting Activities
MRI		Electric Stim		Part-Time Work
CT Scan		Myostim		Stopping Work
EMG/NVC		Massage		Bed Rest
Bone Scan		Pool Therapy		Anti-Inflammatory Meds
Bone Density		Stationary Bike		Muscle Relaxants
Myelogram		Strengthening Exercises		Pain Medication
Ultrasound		Stretching Exercises		No Treatment to Date
Chiropractor		Epidural Steroid Injection		Other: