New Patient Form

New Patient Form

For new patients, fill out the form below.

Our Pain Care Treatments
& Specialties

Our Office Location

For new patients, fill out the form below.

Our Pain Care Treatments & Specialties

Our Office Location

Our Pain Care Treatments
& Specialties

Demographics

Pain

Please check the boxes for any symptoms you are currently experiencing.

Medical History

Pharmacy & Medication

Tobacco & Alcohol Questionnaire

Emergency Contact

Billing & Insurance Information

Referral Information

Demographics

Pain

Please check the boxes for any symptoms you are currently experiencing.

Medical History

Pharmacy & Medication

Tobacco & Alcohol Questionnaire

Emergency Contact

Billing & Insurance Information

Referral Information

Even though we are committed to compassionate care, we must exercise proper due diligence when prescribing opioid analgesics for chronic pain in order to follow state and federal guidelines. Therefore, our clinic policy is that an appropriate workup must be completed prior to the dispensing of any controlled prescription. This workup will include review of previous pharmacy/clinic records, evaluation by diagnostic and laboratory tests, and acceptable completion of a urine drug screen yielding expected results. Our clinic policy is to never co-prescribe benzodiazepines and opiate pain medications.

Please bring your driver’s license and insurance cards along with your completed new patient paperwork to your scheduled appointment. Payment for services is expected at the time of service (co- pays, co-insurance, private pay). We accept check, money order and
credit cards (Visa, American Express, MasterCard, and Discover).
If you have been instructed to obtain imaging reports and/or films by our staff, please bring them to your appointment. Our office requires these as part of your consultation. If we do not have your films at the time of your appointment, you may be rescheduled.
Your initial visit at the Practice is a consultation. If a doctor referred you for an injection, you must be seen for an office visit first. Procedures are scheduled after the initial consultation.
If English is your second language, please make arrangements for someone to accompany you to your visit who can translate in order to provide you with the best healthcare service. We want you to fully understand your diagnosis and prognosis and have any questions you may have answered.

Name(Required)

First MI Last

Gender

Male

Female

Date of Birth(Required)

Social Security #(Required)

Marital Status(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email(Required)

Cell Phone

Home Phone

Work Phone

Pain Complaint(Required)

Secondary to:

Illness

Accident

Work

Other

Date of the onset of pain:(Required)

How often do you have pain:(Required)

Constant

Intermittent

Type of Pain:(Required)

Aching

Throbbing

Sharp

Shooting

Stabbing

Burning

How bad is your pain on average?(Required)

Please enter a number less than or equal to 10.

How bad is your pain at its worst:(Required)

Please enter a number less than or equal to 10.

What makes your pain better?

What makes your pain worse?

General

Fever

Chills

Night Sweats

Weight Loss

Loss of Apetite

Insomnia

Fatigue

Depression

HEENT

Changes in Vision

Dry Mouth

Double Vision

Blurry Vision

Dizziness

Difficulty Swallowing

Runny Nose

Ear Pain

Swollen Glands

Cardiovascular

Chest Pain

Shortness of Breath

Palpitations

Poor Circulation

Difficulty Laying Flat

Absent Pulses

Skin

Rashes

Infections

Ulcers

Discoloration

Swelling

Neurologic

Confusion

Dizziness

Loss of Balance

Numbness

Respiratory

Shortness of Breath

Wheezing

Cough

Supplemental Oxygen Use

Genitourinary

Difficulty Urinating

Pain with Urination

Pelvic Pain

Incontinence

Gastrointestinal

Heartburn/Reflux

Difficulty Swallowing

Constipation

Diarrhea

Psychiatric

Depressed Mood

Substance Abuse

Difficulty Sleeping

MSK

Joint Pain

Back Pain

Neck Pain

Joint Swelling/Deformity

Difficulty Ambulating

Joint Stiffness

Please list any medical conditions you have been diagnosed with.

Click the plus icon to add more rows.

Please list any hospitalizations and surgeries you have had in the PAST YEAR.

Click the plus icon to add more rows.

Please list any treatments you have had in the PAST YEAR. (Physical Therapy, Injections, Acupuncture)

Click the plus icon to add more rows.

Are you pregnant?(Required)

Yes

If so, how many months?

Pharmacy(Required)

Pharmacy #

Address(Required)

Phone(Required)

Are you currently taking aspirin?(Required)

Yes

If so, what dosage?

Are you currently taking a blood thinner?(Required)

Yes

If so, what?

Please list any medications you are currently taking:

Name of Medication / Dosage / how often. Click the plus icon to add more rows.

Medication

Please list any Medication Allergies / Adverse Reactions

Click the plus icon to add more rows.

Allergy

Tobacco(Required)

If you are currently using or formally used any of the Tobacco products above, please list the date you last used each type.

Alcohol(Required)

If you are currently using or formally used any of the Alcohol products above, please list the date you last used each type.

Emergency Contact(Required)

First Last

Relationship(Required)

Spouse

Parent

Sibling

Other

Emergency Contact Phone

1. Primary Insurance(Required)

*Write self-pay if you don't have insurance.

Policy Holder Name

DOB

Phone

2. Secondary Insurance

Policy Holder Name

DOB

Phone

Guarantor’s Name (if different from above)

DOB

Primary Care Dr. (First & Last Name)(Required)

First Last

Phone(Required)

Were you referred by a Physician(Required)

Yes

Referred By (First & Last Name)

First Last

Phone

Language(Required)

English

Spanish

Other

Interpreter Needed?(Required)

Yes

Ethnicity(Required)

Hispanic or Latino

Decline

Other

Race(Required)

White

American Indian

Black or African American

Hawaiian or Other Pacific Islander

Asian

Decline

Other

Name

This field is for validation purposes and should be left unchanged.

Monday – Friday:
8:00 am – 5:00 pm

Se habla Español

731 Carnoustie Drive, Suite 102
San Antonio, TX 78258

	Light	Occasional	Social	Heavy	Former	Never
Beer
Wine
Hard Liquor

Occasional

Cigarettes

Chewing Tobacco

Dipping Tobacco