New Patient Q&A
PATIENT INFORMATION
First Name


Last Name


Date of Birth
What is your CURRENT level of pain? Do not exaggerate, so we can best assess your pain
1 2 3 4 5 6 7 8 9 10
What is your HIGHEST level of pain? Do not exaggerate, so we can best assess your pain
1 2 3 4 5 6 7 8 9 10
How much of the day are you in pain?
Up to 25% Up to 50% Up to 75% More Than 75%
What does your pain FEEL like? Check all that apply
Stabbing Burning Shooting Throbbing

Aching Numb Tingling Other
On an AVERAGE night ...
How many total hours of sleep do you achieve?
How many times do you wake up because of your pain?
0 - 1 times 2 - 3 times 4 or more times
Are you currently WORKING?
Yes No
How many hours a week are you working?
0 - 10 Hours 11 - 20 Hours

21 - 30 Hours 32 Hours or more
How often do you currently SMOKE?
Never Rarely 1 - 2 times a week

3 - 5 times a week Everyday
How often do you currently drink ALCOHOL?
Never Rarely 1 - 2 times a week

3 - 5 times a week Everyday
Have you ever suffered from DRUG and/or ALCOHOL addiction or abuse?
Yes No
What is your MARITAL STATUS?
Single Married Separated Divorced Widowed
If you have CHILDREN, how many are living with you?
Do you have any Family Members who suffer from
severe DEPRESSION and/or ANXIETY disorder?
Yes No
Do you have any Family Members who suffer from
DRUG and/or ALCOHOL addiction?
Yes No
Do you EXERCISE?
Yes No
How many times do you exercise per WEEK?
1 - 2 3 - 4 5 - 6 7 or more
How long do you exercise per SESSION?
up to 10 mins 15 - 20 mins

30 - 45 mins 45 mins or more
What exercises do you do? Check all that apply
Walking Hiking Stretching Gym

Biking Treadmill Elliptical Yoga

Swimming Weights
Check the boxes if you experience ANY of the following: Check all that apply
Recent Weight Loss Fever or Chills Excessive Thirst

Frequent Nosebleeds Hearing Loss Chest Pain

Shortness of Breath Heartburn Bloody Stool

Weakness with Urination Weakness with Bowel Movements

Take Blood Thinners Red, Hot, or Swollen Joints

Frequent Anxiety Depression
In the last 30 DAYS, how much has your pain interfered
with DAILY or GENERAL activities? 10 = "completely interferes"
0 1 2 3 4 5 6 7 8 9 10
In the last 30 DAYS, how much has your pain interfered
with RECREATIONAL, SOCIAL, or FAMILY activities? 10 = "completely interferes"
0 1 2 3 4 5 6 7 8 9 10
In the last 30 DAYS, how much has your pain interfered
with your ability to WORK and HOUSEWORK? 10 = "completely interferes"
0 1 2 3 4 5 6 7 8 9 10
In the last 3 MONTHS, how many days have you been UNABLE to work?
0 - 3 Days 4 - 7 Days 8 - 14 Days More than 14 Days
In the last 3 MONTHS, how many days have you been
UNABLE to do housework or schoolwork?
0 - 3 Days 4 - 7 Days 8 - 14 Days More than 14 Days