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2022 BEST PAIN MANAGEMENT
New Patient WC
DG Pain Management
Patient Health History - Intake Form
Name
Today's Date
Social Security
Address
City
State
ZIP Code
Date of Birth
Sex:
*
Male
Female
Home Phone
Cell Phone
Email
Can we text you?
*
Yes
No
Marital Status:
*
Single
Married
Divorced
Widow
Separated
MVA / Car Accident
Insurance Name
WCB Number
Claim Number
Date of Accident
Adjuster's Name
Adjuster's Phone Number
Worker's Compensation
Insurance Name
WCB Number
Claim Number
Date of Accident
Adjuster's Name
Adjuster's Phone Number
Attorney
Firm:
Phone Number
Lawyer
Address
Employment
Currently Employed
*
Yes
No
Retired
Disabled
Student
Occupation
Employer
Address
City
State
ZIP Code
Phone Number
Supervisor
Health Insurance
Insurance Company
Effective Date
Insurance ID
Group Number
Please enter policy holder information below, if you are the policy holder check off here:
I am the policy holder
Policyholder's Name (Last, First, Middle)
Relationship to Patient
Social Security
Date of Birth
Contact
Emergency Contact
Phone Number
Relationship
Who referred you to Pain Management Associates?
Primary Care Physician
Phone Number
Patient Name
Today's Date
Please indicate your level of pain
*
1
2
3
4
5
6
7
8
9
10
What caused your pain?
Work Related
Car Accident
Accident Date
Describe accident
Have you had any injuries in your area of pain prior to the accident?
*
Yes
No
Have you ever been treated for the area of pain prior to the accident?
*
Yes
No
Have you tried other treatments for this condition?
*
Yes
No
If so, what treatments?
Chiropractor
*
Yes
No
Start Date
Duration / # of Times
Area
Rating
1
2
3
4
Physical Therapy
*
Yes
No
Start Date
Where
Type
Area
Continue
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