Patient Forms

You may access the following forms to assist us with your care. Please complete the following forms prior to your appointment. For records release or requests, please click on the required form below, print out and complete it and bring to your appointment. 


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Patient Health History 1

HEALTH HISTORY

DATE: 

PATIENT NAME: 

DATE OF BIRTH: 

ALLERGIES TO MEDICATIONS/ OTHER: 

IF YES PLESE LIST ALLERGIES: 

TAKING BLOOD THINNING MEDICATION?: 

IF YES PLEASE LIST MEDICATIONS: 

CURRENT MEDICATIONS/ DOSAGE/ HOW TAKEN AND REASON: 

 

PAST MEDICAL HISTORY

Check if you have ever had any of the following:

 

PREVIOUS HOSPITALIZATION/ SURGERIES

Check if you have ever had any of the following:

 

FAMILY HISTORY 

CHECK IF ANY OF THE FOLLOWING APPLY AND SELECT WHICH PARENT:


 

PATIENT SOCIAL HISTORY

SELECT APPROPRIATE RESPONSE:

 USE OF ALCOHOL 

  • DRINKS PER WEEK 
  • TYPE OF ALCOHOL 

 USE OF DRUGS

  • TIMES PER WEEK 
  • DRUG TYPE

 USE OF TOBACCO

  • PREVIOUSLY QUIT- DATE 
  • CURRENT PACKS PER DAY: 
  • # YEARS OF SMOKING: 
  • SMOKELESS TOBACCO USE: 

 BY SELECTING YES, I AM CONFIRMING THAT TO THE BEST OF MY KNOWLEDGE, THE QUESTIONS ON THIS FORM HAVE BEEN ACCURATELY ANSWERED. I UNDERSTAND THAT PROVIDING INCORRECT INFORMAITON CAN BE DANGEROUS TO MY HEALTH. IT IS MY RESPONSIBILITY TO INFORM THE DOCTOR'S OFFICE OF ANY CHANGES IN MY MEDICAL STATUS. I CONSENT TO HAVING TREATMENT WITH THE PHYSICIANS AT NEUROSPINECARE, INC. 

 

 

 

 



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Patient Demographic Information

PATIENT DEMOGRAPHIC INFORMATION

NAME: 

AGE: 

SEX: MALE FEMALE

ADDRESS: 

CITY:      

STATE:      

ZIP: 

MARITAL STATUS: 

SOCIAL SECURITY NUMBER:       

BIRTHDATE: 

HOME PHONE:    

EMAIL ADDRESS: 

EMPLOYER:    

EMPLOYER PHONE NUMBER: 

EMERGENCY CONTACT NAME:    

EMERGENCY CONTACT RELATIONSHIP: 

EMERGENCY CONTACT PHONE NUMBER: 

FAMILY PHYSICIAN:    

FAMILY PHYSICIAN PHONE NUMBER: 

REFERRING PHYSICIAN:    

REFERRING PHYSICIAN PHONE NUMBER: 

CAN WE CONTACT YOU VIA YOUR EMAIL ADDRESS? YESNO


INSURANCE INFORMATION

PRIMARY INSURANCE:    

SUBSCRIBER NAME: 

SUBSCRIBER SOCIAL SECURITY NUMBER:    

SUBSCRIBER BIRTHDATE: 

SECONDARY INSURANCE:    

SUBSCRIBER NAME: 

SUBSCRIBER SOCIAL SECURITY NUMBER:    

SUBSCRIBER BIRTHDATE: 

ARE REFERRALS REQUIRED FROM YOUR PCP FOR SPECIALIST VISITS? YESNO


IS CONDITION DUE TO A WORK RELATED INJURY? YESNO 

IF YES, PLEASE COMPLETE INFORMATION BELOW

DATE OF INJURY:    

BWC CLAIM NUMBER: 

BRIEFLY DESCRIBE INJURY/ACCIDENT: 


RESPONSIBLE PARTY: SELF OTHER

NAME: 

ADDRESS:    

PHONE: 

PREFERRED PHARMACY NAME AND PHONE NUMBER: 

BY SELECTING YES, I AM CONFIRMING THAT I AUTHORIZE ALL PAYMENTS FOR TREATMENT BE SENT DIRECTLY TO NEUROSPINECARE, INC. INCLUDING MEDICARE AND PRIVATE PAYORS. I UNDERSTAND THAT THE NOTICE OF PRIVACY PRACTICES ARE POSTED ON THE WEBSITE AND A PAPER COPY IS AVAILABLE TO ME AT THE OFFICE. I WILL ABIDE BY THE FINANCIAL POLICIES SET FORTH BY NEUROSPINECARE, INC. AND MAY REQUEST COPY OF SUCH NOTICE.

TODAYS DATE: 



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