NEW PATIENT QUESTIONNAIRE - Pain Free New Mexico
NEW PATIENT QUESTIONNAIRE
Date of Intake: ____________ Date of Scheduling New Patient Appt: ____________
1. Is this a work related injury? Yes
Name: ______________________________Phone: ___________________________
Date of Birth: ________________ Social Security #: _________________________
Insurance Primary:_____________________
Attorney_____________________________ Adjuster___________________________
Disclaimer: We do not accept workers comp insurance from the department of labor, the state of California, or the state of Texas.
2. Is this injury the result of a motor vehicle accident?
MVA Attorney: _________________
Attorney Phone Number: __________________
3. Non work related injuries (If this injury is work related, ignore this section)
Name: ______________________________Phone: ___________________________
Address:______________________________________________________________
Date of Birth: ________________ Social Security #: _________________________
Insurance Primary:_____________________ Senior Centennial Commercial
Referring Physician___________________
Referring Physician Phone #: ____________________
Primary Group #____________________ Primary ID #_____________________________
Insurance Secondary__________________________
MVA: Attorney(LOP)__________________________ (will not bill MVA Ins)
A. Area of pain? ____Neck ____Upper back ____Low back ____Leg
Other (specify) ______________________________________________________
B. Have imaging studies been performed for the area of pain? Such as:
MRI’s of the neck? Yes No MRI’s of the back? Yes No
CT scans of the head? Yes No Where were studies done? __________________
C. Have you seen other pain physicians? Yes No
If Yes , whom have you seen? __________________________________________
D. Are you taking narcotics? List Name/Dosage/# per day. Are you taking Soma? Yes No
_________________________________________________________________
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