Pain Primary Packet Pain Management New Patient Packet Name* First Middle Last Date of Birth:* Date Format: MM slash DD slash YYYY Age:*Sex:*MaleFemaleSocial Security Number:*Marital Status:SingleMarriedPhone (Cell)Phone (Home) AddressAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Emergency Contact:Name:*Relationship*Emergency Contact Phone*Primary Insurance Information:Carrier/Insurance Name:Member/Policy Number:Subscriber Information:SelfOtherIf "Other" individual, name and date of birth of individual:Medicare Member #:(only complete if you have Medicare)Florida Medicaid Member #(only complete if you have Florida Medicaid)Secondary Insurance Information:Carrier/Insurance Name:Member/Policy Number:Subscriber Information:Self:Other:If "Other" individual, name and date of birth of individual:Current Medical ConditionsDo you have any CURRENT conditions you are being treated for?*YesNoCurrent Conditions QuestionsPlease choose "yes" if you are CURRENTLY being treated for any of these conditions. Anxiety*YesNoChoose any symptoms you are having related to anxiety:* Agitation Feeling Overwhelmed Insomnia Palpitations Guilt Hopelessness Loss of interest Fatigue Depression*YesNoChoose any symptoms you are having related to depression:* Agitation Feeling Overwhelmed Insomnia Palpitations Guilt Hopelessness Loss of interest Fatigue Asthma*YesNoSymptoms:*Made worse by:*What makes it better:*Frequency of episodes:*When were you diagnosed:*Are you on medication?*YesNoHigh Cholesterol*YesNoCheck any symptoms you are having related to your cholesterol:* Numbness Tingling Headache Fatigue Blurry Vision Chest Pain Shortness of Breath Ankle Swelling Dizziness Heart Disease*YesNoCheck any symptoms related to your heart disease:* Current Smoker? History of Diabetes? Dizziness Previous stent placement Chest pain? Weakness? Headache? Intestinal Problems*YesNoCheck any current symptoms you have related to your intestines:* Abdominal Pain? Anorexia Nausea Vomiting Diarrhea Constipation Indigestion Arthritis*YesNoWhere is your arthritis located?*Check all that apply related to your arthritis:* Currently on medications? Joint pain Joint swelling Joint weakness Morning stiffness Fevers? Allergies*YesNoWhat symptoms do you have?*What makes allergies worse?*What makes allergies better?*How long have you experienced symptoms?*Frequency of allergic episodes?*Are you currently on allergy medications?*YesNoDiabetes*YesNoWhat type of diabetes do you have?*Type 1Type 2Check any symptoms you have related to your diabetes?* Fatigue Frequent urination frequently hungery thirsty Blurry vision Dizziness Weight loss Numbness High Blood Pressure*YesNoCheck any symptoms you have related to your high blood pressure?* Chest pain Headache Blurred vision Dizziness Shortness of breath Hypothyroidism*YesNoAre you on medication for your hypothyroidism?*yesnoCheck all symptoms you have related to your hypothyroidism:* Weight gain Dry skin Constipation Cold sensitivity Irregular menses Depression Hair loss Other Conditions:Past Medical HistoryCurrent MedicationsPlease list CURRENT medications you are taking. Medical History*Choose all that apply to you. Abuse Abnormal PAP Anemia Anxiety/Nerves Asthma Allergies Alcoholism/substance use Bleeding Disorder Blood transfusion Blood Clots Cancer High Cholesterol Chronic Pain Depression Diabetes Epilepsy Genetic Disease Glaucoma Gout Migraines Heart Disease Hepatitis High Blood Pressure Intestinal problems Kidney Disease Lung Disease Osteoporosis Sexual disease stroke Thyroid disease Tuberculosis Stomach ulcer Allergies None Penicillin Sulfa Drugs Latex Contrast Dye Aspirin Seasonal Allergies Other: Other Allergies:*Past Surgical History Appendectomy Tonsilectomy Hysterectomy Gallbladder Removal Heart Surgery/Cath Vasectomy Hernia Repair Amputation Tumor Removal Mastectomy C-Section Back Surgery Colectomy Other Please choose all the surgeries you have had in the pastList additional surgeries here:*Past HospitilizationsList Dates and Reason you were hospitalized:Family HistoryIs your mother alive?YesNoAge she passed away and reason?*Is your father alive?YesNoAge he passed away and reason?Do you have any children?YesNoHow many sons?*How many daughters?*Are they all healthy?*Do you have any siblings?YesNoDo you have any brothers?YesNoHow many brothers and are they healthy?*Do you have any sisters?YesNoHow many sisters and are they healthy?*Social HistoryDo you smoke cigarettes?*YesNoHow many cigarettes per day?1-55-101 pack1.5 packs2 packsmore than 2 packs per dayHave you ever smoked cigarettes?*YesNohow long ago did you quit?*Do you drink alcohol?YesNoHow often do you drink alcohol?*Do you use any illegal drugs?*YesNoWhich illegal drugs do you use?*Review of Current Symptoms?Are you CURRENTLY experiencing any symptoms that concern you?*YesNoPick all symptoms you are CURRENTLY having:General Weight loss or gain Fatigue Fever or chills Weakness Trouble Sleeping Ears, Nose, Throat, or Mouth Symptoms*YesNoWhich Ears, Nose, Throat, or Mouth Symptoms do you have?* Decreased hearing Tinnitus (ringing in ears) Earache Ear Drainage Epistaxis (Nosebleed) Sinus Pain Sore Throat Hoarseness Thrush Dry Mouth Toothache Pain with swallowing Stiffness Runny Nose Respiratory Symptoms*YesNoWhich respiratory symptoms do you have?* Cough Sputum Wheezing Coughing up blood Shortness of breath Pain with breathing Asthma Vascular Symptoms*YesNoWhich vascular symptoms do you have? Calf pain with walking Leg cramping Psychiatric Symptoms*YesNoWhich psychiatric symptoms do you have?* Depression Anxiety Difficulty Concentrating Paranoia Sadness Mania Altered Mental Status Cardiovascular Symptoms*YesNoWhich cardiovascular symptoms do you have?* Hypertension Hyperlipidemia Chest pain Chest tightness Palpitations Shortness of breath with activity Difficulty breathing lying down Swelling Sudden awakening from sleep with shortness of breath Gastrointestinal Symptoms*YesNoWhich gastrointestinal symptoms do you have?* Abdominal Pain/Cramping Difficulty swallowing Heartburn/indigestion Change in appetite Black tarry stools Nausea/vomiting Diarrhea Vomiting blood Rectal bleeding Change in bowel habits Genitourinary Symptoms*YesNowhich genitourinary symptoms do you have?* Urine frequency Blood in urine Incontinence Dysuria Nocturia Hematuria Polyuria Pain or burning with urination Difficulty with erection Vaginal discharge Vaginal pain Menopause Musculoskeletal Symptoms*YesNoWhich musculoskeletal symptoms do you have?* Muscle or joint pain Stiffness Back pain Worsens with activity Joint swelling Decreased range of motion Arthritis Weakness Muscle Cramping Neurological Symptoms*YesNoNeurological* Change in sight, smell, hearing, or taste Headache Fainting Seizures Weakness Trouble with balance Numbness/tingling Tremor Memory loss Speech problems Fainting Health MaintenanceHave you ever had your cholesterol levels checked?*YesNoWhat year did you last have this done?*Have you ever had a mammogram?YesNoWhen was your last mammogram?*Have you ever had a colonoscopy?YesNoWhen was your last colonoscopy?*Have you ever had a pap smear?YesNoWhen was your last pap smear?*Have you ever had your PSA checked?YesNoWhen was your PSA last checked?*Have you ever had a DEXA scan?YesNoWhen was your last DEXA scan?*Have you ever been immunized against Pneumonia?YesNoWhen was your Pneumonia shot?*Have you ever had a tetanus shot?YesNoWhen was your last tetanus shot?*Have you ever had a flu shot?YesNoWhen was your last flu shot?*