Patient First Name* First Middle* Middle Last Name* Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican 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 RicoQatarRéunionRomaniaRussiaRwandaSaint 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 IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Date of Birth AgeSocial Security NumberSexMaleFemaleEmail Home PhoneMobile PhoneWork PhonePharmacy NamePharmacy Phone NumberPharmacy Address or Cross Streets Street Address Emergency Contact Person’s Name First Emergency Contact PhoneEmployer First Employer Address Street Address 1.Office communication regarding appointments and test resultsPreferred Language:EnglishSpanishCreoleDo we have your permission to send you text messages regarding appointments and test results?YesNoDo we have your permission to leave voicemail messages regarding appointments and test results?YesNoDo we have your permission to send you email communication regarding appointments and test results?YesNoPrimary Insurance Company NamePrimary Insurance Company Phone NumberInsurance ID#Insurance Group#Insurance Claims address: Street Address Secondary Insurance Company NamePrimary Insurance Company Phone NumberInsurance ID#Insurance Group#Insurance Claims address: Street Address Is this visit related to an accident?YesNoIf yes, date of your accident related injury: If Yes, what type of accident:Motor VehicleSlip & FallWorker’s CompAttorney / Firm Name:Address City State / Province / Region Attorney Phone Number:2.General and Social Health HistoryHeightWeightSmoking StatusNever SmokedFormer SmokerCurrent SmokerHow much per dayDo you have a problem with or history of substance abuse?YesNoIf yes, check all that apply: Alcohol Illicit drugs Prescription drugs Illicit drugs:Prescription drugsCurrent Alcohol Use?YesNoIf yesDailySocialOccasionalRarelyNeverAllergies/Adverse Reactions/SensitivitiesList Medication AllergiesAre you allergic or sensitive to adhesive tape?YesNoIV Contrast/x-ray dye/Iodine or Shell fish?YesNoAre you allergic or sensitive to LATEX?YesNoDo you have significant Environmental or Food Allergies?YesNoExplain:PrescriptionsDo you currently take prescription medications (including inhalers, blood thinners, or birth control)?YesNoList Medications/Name/Strength/Directions:Vitamins-Herbal Supplements-Over the Counter MedicationDo you currently take over the counter medications, vitamins, or herbal supplements (including Ibuprofen, aspirin, Vitamin B, CoQ10, fish oil, etc)?YesNoList Medications3. Medical History Cataract Glaucoma Ear/Nasal Problems Hearing Problems Headaches Bowel problems Diverticulitis Hiatus Hernia Stomach Ulcer Prostate Problems Diabetes Heart attack/ Angina Bladder problems Seizures Stroke Alzheimer disease Parkinson disease Emphysema/COPD Liver disease Congestive heart failure Arrthymias Heart Disease Mitral valve prolapse Aneurysm Asthma Kidney disease HIV/AIDS Other List any other medical complications.Surgical History: (list all surgeries and year performed)History of cancer:YesNoIf yes, Where?Received:RadiationChemotherapyEXPLAIN:Initial Pain AssessmentOn a scale of 1-10 (10 being the worst pain), what is your pain today?12345678910How did your pain problem start?Unknown reasonMotor vehicle accidentFallLifting eventWhen did it start? If known: what is the cause of your pain?SciaticaDegenerative disc diseaseSpinal stenosisScoliosisArthritisWhat pain medications or therapies have you tried in an attempt to alleviate the pain?Muscle RelaxersAnti-inflammatorySpinal stenosisOpioids/NarcoticsChiropractic/Physical TherapySpinal InjectionsWhat tests and studies have been done? (X-ray, CT scan, MRI) X-rays MRI CT Scan What other things have you tried? of what body part(s)Date This iframe contains the logic required to handle Ajax powered Gravity Forms.