South Pointe Medical - New Patient Questionnaire

South Pointe Medical - Back and Spine Center

To expedite your initial visit, you may complete the following online new patient questionnaire below.

If you prefer to complete a paper copy of your new patient questionnaire and bring it to your first visit, click here to download the forms.

If your injury is due to an AUTO ACCIDENT, please click here for the appropriate intake form.

If your injury is due to a WORK INJURY, please click here for the appropriate intake form.

Upon completion, please click the "Submit" button. Your information is secure, and will immediately be sent to your doctor, who will review your intake information before your visit.

Please complete all questions.

Online New Patient Questionnaire


ADMINISTRATIVE QUESTIONS
Today's Date:
Full Name:
Address:
City, State, Zip:
Phone Number You Can Be Reached At:
E-mail:
Age:
Birth Date:
Marital Status:
Employment Status:
Occupation:
Employer:
Primary Care Physician:
Location of Primary Care Physician:
Insurance Company:
Type of Payment:
Emergency Contact:
Relationship of Emergency Contact:
Referred to Our Office By:
Name of Person Who Referred You (if applicable):
SYMPTOM QUESTIONS
Location of symptoms: Head Neck Shoulder(s) Midback Ribs Low Back Buttocks Hip(s) Leg(s) Knee(s) Ankle(s) Feet Elbow(s) Wrist(s) Hand(s) Chest Other
Describe your symptoms:
When did your symptoms begin?
How did your symptoms begin?
How often do you experience your symptoms? Constantly (76-100% of the day) Frequently (51-75% of the day) Occasionally (26-50% of the day) Intermittently (0-25% of the day)
What describes the nature of your symptoms (check all that apply)? Sharp Dull Numb Tingling Stabbing Burning Sore Shooting
How are your symptoms changing? Not Changing Getting Better Getting Worse
How bad are your symptoms AT BEST (on a scale of 1-10 with 1 being pain that is almost unnoticable and 10 being unbearable pain)?
How bad are your symptoms AT WORST (on a scale of 1-10 with 1 being pain that is almost unnoticable and 10 being unbearable pain)?
How do your symptoms affect your ability to perform daily activities? Not At All A Little Bit Moderately Quite A Bit Extremely
What activities make your symptoms worse?
What activities make your symptoms better?
Who have you seen for your symptoms? No One Medical Doctor Chiropractor Physical Therapist Massage Therapist Acupuncturist Other
What tests have been performed for this condition (if applicable, please bring a copy of your tests to your appointment)? None X-rays MRI CT Scan Nerve Conduction Test Blood Test Other
Have you had similar symptoms in the past? Yes No
Is this a recurring problem? Yes No
If this is a recurring problem, how often do you experience these symptoms? Not Applicable Less than once per year 1-2 times per year 3-6 times per year More than 6 times per year
If you have had similar symptoms in the past, who did you see (check all that apply)? Not Applicable No One Medical Doctor Chiropractor Physical Therapist Massage Therapist Acupuncturist Other
Are you currently seeing other healthcare providers for any other condition? Yes No
If yes, please list providers and the condition being treated:
What do you hope to get out of your visit at the Back and Spine Center (check all that apply)? Reduce Symptoms Resume or Increase Activity Explanation of Condition and Treatment Learn How to Take Care of Myself Learn How to Prevent This Condition Other
Hang in there, you are almost done!
HEALTH HISTORY QUESTIONS
Please check any of the following symptoms which you now have or have had previously (check all that apply).
General Allergies Chills Convulsions Dizziness Fainting Fatigue Fever Headache Loss of Sleep Unexplained Weight Loss Nerve Pain (radiating pain) Nervousness/Depression Numbness Sweats Tremors
Muscle and Joint Arthritis Bursitis Foot Problems Hernia Low Back Pain Neck Pain or Stiffness Midback Pain Shoulder Pain Arm Pain or Numbness Elbow Pain Wrist or Hand Pain or Numbness Pain in Ribs Hip Pain Leg Pain or Numbness Knee Pain Foot Pain or Numbness Painful Tail Bone Poor Posture Sciatica Scoliosis Swollen Joints TMJ Pain (jaw problems)
Cardiovascular Angina Blood Clotting Disorder Hardening of Arteries Heart Murmur High Blood Pressure High Cholesterol Low Blood Pressure Poor Circulation Rapid Heart Beat Slow Heart Beat Swelling of Ankles
Respiratory Chest Pain Chronic Cough Coughing Up Blood Coughing Up Phlegm Difficulty Breathing Wheezing
Skin Acne Boils Bruise Easily Dryness Hives Itching Rash Varicose Veins
Genito-Urinary Bed Wetting Blood In Urine Frequent Urination Kidney Infection Kidney Stones Painful Urination Prostate Trouble Urinary Incontinence Urine Discoloration
For Women Only Congested Breasts Cramps or Backache Excessive Menstrual Flow Hot Flashes Irregular Menstrual Cycle Menopausal Symptoms Painful Menstruation Vaginal Discharge
Women: Are you pregnant? Yes No Maybe
Gastro-intestinal Belching or Gas Blood in Stool Colitis Colon Cancer Colon Trouble Constipation Diarrhea Digestive Difficulties Distension of Abdomen Excessive Hunger Gallbladder Trouble or Stones Hemorrhoids Intestinal Parasites Jaundice Liver Trouble Nausea Poor Appitite Stomach Pain or Cramping Vomiting Vomiting Blood
Eyes, Ears, Nose, & Throat Asthma Colds Crossed Eyes Deafness Dental Decay Ear Infections Ear Discharge Ringing in Ear (tinnitus) Enlarged Thyroid Eye Pain Blurry Vision Near Sightedness Far Sightedness Gum Trouble Hay Fever Hoarseness Nasal Obstruction Chronic Nosebleeds Recurring Sinus Infections Tonsillitis
Check any of the following conditions you have had: Abdominal Aneurysm Alcoholism Anemia Appendicitis Arteriosclerosis Arthritis Cancer Chorea Cold Sores Degenerative Disc Disease Diabetes Diptheria Eczema Emphysema Epilepsy Goiter Gout Heart Disease Malaria Measles Multiple Sclerosis Mumps Pleurisy Pneumonia Polio Rheumatic Fever Scoliosis Spinal Disc Herniation Stroke Tuberculosis Ulcers Whooping Cough
List any surgeries you have had and the years performed:
Medication you are currently taking: None Anti-depressants Aspirin Birth Control Pills Blood Pressure Medications Cholesterol Medications Ibuprofen Muscle Relaxants Pain Killers Other
Please list any medications not listed above that you are taking:
Have you been in an auto accident? Never Within last 6 months Within last year 1-2 years ago 2-5 years ago Over 5 years ago
If yes, please describe the accident and any injuries incurred:
Have you ever been seriously injured (excluding auto accidents)? Yes No
If yes, please describe:
Please include any additional information you would like your doctor to be aware of...
VERY IMPORTANT:
Congratulations! You have completed the intake procedure. Before clicking "Submit" below, please highlight the entire page, then copy and paste your form into a word document and save the document. This is to ensure you have a copy in case of an error in the transmission process. After you make a copy, please click the "Submit" button. Your doctor will receive your information within minutes!