New Patient Form New Patient Form Laser Spine Center New Patient IntakeYou are in a secure area so please fill out the New Patient Registration Form before you come for your consultation. Once completed, click on submit and we will have your information when you come in.Please enable JavaScript in your browser to complete this form.Reason for your visit (check all that apply):Neck PainBack PainExtremity pain, tingling or numbnessBrain InjuryHeadachesLaser Spine Surgery ConsultSurgical ConsultSurgical 2nd OpinionPain ManagementAuto AccidentWork AccidentNeed MRIName *FirstLastDate of BirthMarital StatusSingleMarriedDivorcedWidowedAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhoneEmail *EmploymentFull TimePart TimeNot Currently EmployedHomemakerOn DisabilityOccupationEmployerEmployer AddressHealth Insurance InformationPrimary InsuranceInsurance ID#Group#Secondary InsuranceSecondary Insurance ID#Secondary Insurance Group#Primary Care NamePrimary Care PhoneChiropractor NameChiropractor PhonePharmacyPharmacy AddressAccident Related QuestionsIs this related to:Auto AccidentWork AccidentFall or OtherNot Related to an AccidentAuto Insurance AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeYour auto insurance nameAuto Insurance PhoneAdjuster name, if work relatedHave you seen any other doctors for this injury?ChiropractorPhysical TherapistOrthopedicsFamily doctorOtherImaging Tests DoneX-Ray(s)MRI(s)CT Scan(s)OtherDate of Injury or AccidentPlease state the reason you are here todayPlease list past surgeriesPlease list all medications you are currently takingPlease list all allergies to drugs or foodDo you presently use or have used illicit drugs such as cocaine?NoYesDo you drink alcohol?NoYesDo you smoke?NoYesHow often?MonthlyWeeklyDailyOnly special occasionsFamily Medical HistoryMother HistoryDiabetesCancerHeart DiseaseHypertensionStrokeDeceasedN/AFather HistoryDiabetesCancerHeart DiseaseHypertensionStrokeDeceasedN/ABrother(s)DiabetesCancerHeart DiseaseHypertensionStrokeDeceasedN/ASister(s)DiabetesCancerHeart DiseaseHypertensionStrokeDeceasedN/APersonal Medical HistoryPlease check all that apply to youPalpitationsChest PainWeight LossWeight GainMuscle CrampsBack PainNeck PainHeadachesAnxietySyncope or FaintingFeet SwellingJoint SwellingJoint StiffnessFeeling HotFeeling ColdHearing ProblemsVision ProblemsCoughShortness of BreathDiarrheaConstipationUrinary SymptomsMedical ConditionsDiabetesCancerHeart DiseaseHypertensionStrokeKidney DiseaseN/AOther medical information you would like us to know?Neck or Arm PainDo you have neck or arm pain?YesNoMy neck pain isConstantFrequentComes and GoesMy arm has feelings ofPainTinglingNumbnessWhich arm do you experience these symptoms?RightLeftBothWhich side is worse?RightLeftHow long have you had arm pain?Less than 6 weeksMore than 6 weeksWhich pain is worse?Neck pain is worse than leg painThey are equalArm pain is worse than back painWhat makes your neck pain worse?What makes your neck pain better?What makes your arm pain worse?What makes your arm pain better?Please check all that applyI have weakness in my right armI have weakness in my left armMy handwriting is getting worseMy balance seems worse latelyI seem to drop things easilyI have difficulty buttoning my shirtsI have numbness in my handsI have numbness in my armsHow much NECK pain are you experiencing on a scale from 0-10 with 0 being no pain & 10 being the worst? Selected Value: 0 How much ARM pain are you experiencing on a scale from 0-10 with 0 being no pain & 10 being the worst? Selected Value: 0 Back or Leg PainDo you have back or leg pain?YesNoMy back pain isConstantFrequentComes and goesMy back pain isabove my belt lineat my belt linebelow my belt lineMy leg pain isConstantFrequentComes and goesThe pain is in myRight legLeft legWhich pain is worse?Back pain is worse than leg painThey are equalLeg pain is worse than back painI have more pain in myRight legLeft legMy back pain is worse withSittingStandingLying downWalkingWhat eases your back pain?SittingStandingLying downWalkingMy leg pain is worse withSittingStandingLying downWalkingWhat eases your leg pain?SittingStandingLying downWalkingHow much BACK pain are you experiencing on a scale from 0-10 with 0 being no pain & 10 being the worst? Selected Value: 0 How much LEG pain are you experiencing on a scale of 0-10 with 0 being no pain & 10 being the worst pain? Selected Value: 0 Treatments You've TriedCheck all that applyChiropracticPhysical TherapyPrimary CareInjectionsPain ManagementTractionSurgeryOtherDo we have your permission to leave a message on the phone number(s) you have provided?YesNoMay we discuss your medical information with...(family, attorney, PCP, chiropractor)YesNoIf someone calls for you or comes in and asks for you while you are here, do we have permission to tell them you are here?YesNoWhom may we discuss your medical records with (please list names)?Consent *By checking, I agree to share my form responses with Allspine Laser and Surgery Center.Submit
