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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