Welcome to our online New Patient Questionnaire. We need
to gather as much information as possible regarding you and your symptoms in
order to begin the process of developing a treatment program tailored just for
The questionnaire is quite thorough and may take several
minutes to complete. Please allow yourself enough time to complete the
requested information in one session. Because we value your privacy, all
information provided is sent directly to treatment specialists and not stored.
If you are unable to complete the questionnaire in a single session, it will be
necessary for you to start over at a later time.
Same as mailing
As best as you understand, why did your referring
physician send you to our clinic?
Are you involved in any court cases or lawsuits?
Do you have a Workers' Compensation claim?
Describe your pain. (mark all that apply)
Where do you hurt? (mark all that apply)
Section 3: Mood
Are you working?
How many hours per week?
What is your occupation?
How many days per month do you take off from work
because of pain?
Section 5: Allergies
Have you ever been told you have a severe
allergy to a medicine?
do you take any blood thinners such as
coumadin, plavix, or lovenox?
do you take any over-the-counter medicines
containing tylenol or acetaminophen?
section 7: other medical problems
list other medical problems (eg. high blood pressure,
diabetes, asthma, etc.)
Please list any previous pain injections/procedures
tried in the past.
Section 9: Family History
List any medical problems that run in your family.
Please indicate all other therapies used to relieve your pain:
Section 11: Social History