Pain Partners, MD

New Patient Intake Forms

ON FOR CARE

Welcome to Pain Partners, MD!

Our Back and Spine Division is the most

comprehensive back pain center in Colorado.
Our integrated approach has resulted in us
being rated as one of the top back pain centers.

We are excited to have the opportunity to earn

your trust and deliver you the best service in
the industry.
INFORMATION/APPLICATI

Thank you for choosing us!

 Pain Partners, MD
Back and Spine Care
Patient Information

The following information is needed in order to better serve you. Please complete all questions. If you need help
please ask the receptionist. PLEASE PRINT.

Today’s Date __________

Name __________________________________ Home Phone ______________ Work Phone ______________
Address ________________________________ City ___________________ State ________ Zip __________
Age _____ Birth date ______________________Marital Status: S M W D Number of Children _________
Your Employer ______________________________ Occupation ____________________________________
Insurance Company ___________________________________ Your Social Security # ___________________
Primary Care Physician:____________________________________Phone #:___________________________
Primary Care Physician Address:________________________City:______________State:____Zip:_________
Do you have Medicare? Yes ____ No ____
Name of Spouse or Parent ___________________________________ Their Birth date ___________________
Referred to our office by: _______________________Your Email:____________________________________
How payment will be made:
__________ Cash __________ Check __________ Credit Card_________
Is your condition due to an accident? Yes _____ No _____ Date of accident?____________________
Type of accident? Auto _____ Work/On Job _____ At Home _____ Other _____________________
Have you ever been in an auto accident? Past Year ____ Past 5 Years ____ Over 5 Years _____Never ______

I (we) agree to pay for services rendered to the above mentioned patient as the charge is incurred. I understand
and agree that health & accident insurance policies are an arrangement between an insurance carrier and myself
and that I am personally responsible for payment of any and all services not covered. I also understand that if I
suspend or terminate my care and treatment, any fee for professional services rendered me will be immediately
due and payable.
Patient’s Signature ___________________________________________ Date _______________________
Or Guardian Signature ________________________________________ Date _______________________

Notice to our new patients: Full payment of the “patient responsibility amount” for services rendered is due at
the end of each visit. If for any reason this request cannot be met, arrangements should be made in advance
before seeing the doctor. _____Initial
In consideration of your undertaking to care for me, I agree to the following:
1. I authorize Colorado Back and Spine Center, P.C. to release any information you deem
appropriate concerning my physical condition to any insurance company, attorney, or adjuster
in order to process any claim for reimbursement of charges I incur.
2. I further agree that this authorization is irrevocable and ongoing until all monies owed are
paid in full.
3. This authorization will be in continual effort until revoked by both parties.

________________________________________________________________________________
Patient/Insured Signature Date

Pain Partners, MD
2
 Back and Spine Care
Patient Health Questionnaire
Patient Name_______________________________________ Date______________________

1. Describe your symptoms

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
a. When did your symptoms
start?____________________________________________________________________________
b. How did your symptoms
begin?____________________________________________________________________________
Indicate where you have pain or other symptoms
2. 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)

3. What describes the nature of your symptoms?

Sharp Dull Numb Shooting
Burning Tingling Sore Stabbing
4. How are your symptoms changing?
Getting Better Not Changing Getting Worse

5. How bad are your symptoms?

None Unbearable
At its WORST 0 1 2 3 4 5 6 7 8 9 10
At its BEST 0 1 2 3 4 5 6 7 8 9 10
6. How do your symptoms affect your ability to perform daily activities? (circle one)
Not at all A little bit Moderately Quite a bit Extremely Severe

7. What activity makes your symptoms worse?_____________________________________

What activity makes your symptoms better?_____________________________________

8. Who have you seen for your symptoms?

No One Chiropractor Medical Doctor Physical Therapist Other
What tests have you had for your symptoms and when were they performed?
Circle all that apply X-rays CT Scan MRI Other
9. Have you had similar symptoms in the past? Yes No

If you have received treatment in the past for the same or similar symptoms, who did you see?
Circle all that apply: This office Chiropractor Medical Doctor Physical Therapist Other

10. Are you currently seeing any health care providers for any other condition? Yes No
If YES, please list provider(s) below:
____________________________________________________________________________
11. What do you hope to get form your visit/treatment (select all that apply)
Reduced symptoms Resume/Increase activity Explanation of condition/treatment
Learn how to take care of this myself How to prevent this from occurring again
Other____________________________

Patient Signature_________________________________ Date________________________

3
 Confidential Patient Case History
Name ___________________________________________________ Date _____________________
Please check the appropriate box for any of the following symptoms which you now have or have had
previously.

O – OCCASIONAL Yes  No Are you

F – FREQUENT CARDIO-VASCULAR pregnant?
C – CONSTANT    Hardening of
O F C arteries O F C
GENERAL    High blood pressure GASTRO-
   Allergy    Low blood pressure INTESTINAL
   Chills    Pain over heart    Belching or gas
   Convulsions    Poor circulation    Colitis
   Dizziness    Rapid heart beat    Colon trouble
   Fainting    Slow heart beat    Constipation
   Fatigue    Swelling of ankles    Diarrhea
   Fever RESPIRATORY    Difficult digestion
   Headache    Chest pain    Distension of
   Loss of sleep    Chronic cough abdomen
   Loss of weight    Difficult breathing    Excessive hunger
      Spitting up blood    Gall bladder trouble
Nervousness/depression    Spitting up phlegm    Hemorrhoids
   Neuralgia    Wheezing    Intestinal worms
   Numbness SKIN    Jaundice
   Sweats    Boils    Liver trouble
   Tremors    Bruise easily    Nausea
MUSCLE & JOINT    Dryness    Pain over stomach
   Arthritis    Hives or allergy    Poor appetite
   Bursitis    Itching    Vomiting
   Foot trouble    Skin eruptions    Vomiting of blood
   Hernia (rash) EYES, EARS, NOSE
   Low back pain    Varicose veins &THROAT
   Lumbago GENITO-URINARY    Asthma
   Neck pain or    Bed-wetting    Colds
stiffness    Blood in urine    Crossed eyes
   Pain between    Frequent urination    Deafness
shoulders    Inability to control    Dental Decay
Pain or numbness kidneys    Earache
in:    Kidney infection or    Ear discharge
   Shoulders stones    Ear noises
   Arms    Painful urination    Enlarged glands
   Elbows    Prostate trouble    Enlarged thyroid
   Hands    Pus in urine    Eye pain
   Hips FOR WOMEN ONLY    Failing vision
   Legs    Congested breasts    Far sightedness
   Knees    Cramps or backache    Gum trouble
   Feet    Excessive menstrual    Hay fever
   Painful tail bone flow    Hoarseness
   Poor posture    Hot flashes    Nasal obstruction
   Sciatica    Irregular cycle    Near sightedness
   Spinal Curvature    Menopausal    Nosebleeds
   Swollen joints symptoms    Sinus infection
   Painful menstruation    Sore throat
   Vaginal discharge    Tonsillitis
4
 CHECK THE FOLLOWING CONDITIONS YOU HAVE HAD:

 Alcoholism  Cold sores  Goiter  Miscarriage  Scarlet fever

 Anemia  Diabetes  Gout  Multiple  Stroke
 Appendicitis  Diphtheria  Heart disease sclerosis  Tuberculosis
  Eczema  Influenza  Mumps  Typhoid fever
Arteriosclerosis  Emphysema  Lumbago  Pleurisy  Ulcers
 Arthritis  Epilepsy  Malaria  Pneumonia  Venereal
 Cancer  Fever blisters  Measles  Polio disease
 Chorea  Rheumatic  Whooping
fever cough

PLEASE PRINT

What’s your major complaint?

_________________________________________________________________________________________________
__________________________________________________________________________________________________
___________________________________
List surgical operation and years:
_____________________________________________________________________________________________
__________________________________________________________________________________________________
___________________________________
Medications you now take:  Nerve pills  Pain killers  Muscle relaxers
 “Pep” pills  Tranquilizers  Birth control pills
Others:
_____________________________________________________________________________________
Age of mattress: ___________________  Comfortable  Uncomfortable  Do you use a bed
board? _________
Are you wearing:  Heal lifts  Sole lifts  Inner soles  Arch supports
Have you been in an auto accident:  Past year  Past five years  Over five years
 Never
Describe:
___________________________________________________________________________________
Have you ever had any mental or emotional disorders?  Yes  No When?
_______________________________
Have others in your family had such disorders?  Yes  No When?
________________________________

HAVE YOU EVER: Yes No DESCRIBE BRIEFLY

Been knocked unconscious?   _______________________________________
Used a cane, crutch, or other support?   _______________________________________
Been treated for a spine or nerve   _______________________________________
disorder?   _______________________________________
Had a fractured bone? _______________________________________
Been hospitalized for anything other   _________________
than surgery?

DO YOU:
Now take vitamins or minerals?
Think you may need vitamins or
minerals?
Have an allergy to any drug?
  ___________________________________________
  ___________________________________________
  ___________________________________________
______________________________

DATE OF LAST:
5
 Spinal examination
Physical Less than 6 6-18 months Over 18 Never
examination months months
Blood test    
Chest X- ray    
Spinal X-ray    
Dental X-ray    
Urine test    
   
  