New Patient Form

Welcome to Harbor Interventional Pain center. As an interventional pain center we do not offer medical management/opiate services. New patients are required to have a referral sent from their referring provider. In order to facilitate your consultation, it is essential that we learn as much about your pain as possible, and that we learn this directly from you. The following questionnaire asks many questions regarding your chronic pain problem. Some questions may seem unrelated to your problem and even unnecessary. Pain is a very complex matter, this questionnaire will give us a comprehensive view of your pain process. We greatly appreciate your cooperation in completing this document to the best of your ability.

Please have any radiologic studies or reports related to you pain faxed to Harbor Interventional Pain Center. Once we receive your questionnaire and radiologic studies we will reach out to you to schedule your consultation appointment. Radiologic studies may be sent to our medical records fax at 603-380-7967. If you have not had radiologic stuides performed you may still be seen for a consultation. However, you may be sent for radiologic studies after having your consultation appointment. Once the radiologic study is recieved and reviewed you may need a follow up consultation to address any additional concerns.

Please note: it is the patient’s responsibility to contact their insurance provider to verify if their insurance provider requires a specialist referral to be seen at Harbor Interventional Pain Center. In some cases, insurance providers will not cover specialist services when the proper referral process is not followed. Not following this process can result in the patient being financially responsible for services rendered at Harbor Interventional Pain Center. If a specialist referral is needed by your insurance provider, your doctor can fax your referral to our medical records fax at (833) 983-2933.

The information you provide on your questonniare is strictly confidential and is for use by Harbor Interventional Pain Center only. The information cannot, and will not, be released to anyone else without your specific written permission.

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1Patient Information

2Insurance Information

3Work History

4Pain History

5Social History

6Medical History

7Consent

Last Name(Required)

First Name(Required)

Middle Initial

First Name Used / Nickname

Physical Address(Required)

Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

Mailing Address(Required)

Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

Email Address(Required)

Home Phone(Required)

Mobile Phone(Required)

Contact Preference(Required)

Home Phone

Mobile Phone

May we leave a voice message?(Required)

Yes

No

Date of Birth(Required)

Month

Day

Year

Social Security No.(Required)

Sex(Required)

Male

Female

Marital Status(Required)

Married

Single

Divorced

Separated

Widowed

Partner

Primary Care Provider(Required)

Pharmacy Information(Required)

Emergency Contact Name(Required)

Relationship(Required)

Home Phone(Required)

Mobile Phone(Required)

Primary Policy / Insurance Plan

Member ID Number

Group ID Number

Relationship to Policy Holder

Is Policy Holder Different From The Patient?

Yes

No

Policy Holder Details

Last Name(Required)

First Name(Required)

Middle Initial(Required)

Address(Required)

Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

Date of Birth(Required)

Month

Day

Year

This field is hidden when viewing the form

Secondary Policy / Insurance Plan

Member ID Number

Group ID Number

Relationship to Policy Holder

Is Policy Holder Different From The Patient?

Yes

No

Policy Holder Details

Last Name(Required)

First Name(Required)

Middle Initial(Required)

Address(Required)

Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

Date of Birth(Required)

MM slash DD slash YYYY

Guarantor Information (If Different From Patient)

Name

Address

Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

Date of Birth

Month

Day

Year

Social Security No.

Home Phone

Mobile

Are you presently employed?(Required)

Yes

No

Employment Nature(Required)

Full Time

Part TIme

Present Occupation(Required)

How long have you been in this position?(Required)

What is your job activity level?(Required)

Sedentary

Light

Moderate

Heavy

How long have you been unemployed?(Required)

Are you applying for compensation/disability for your injury, illness or pain?(Required)

Yes

No

Have you received compensation/disability for your injury, illness or pain?(Required)

Yes

No

Is there any ongoing litigation concerning your injury, illness or pain?(Required)

Yes

No

Explain:(Required)

Where is your pain?(Required)

When did your pain begin?(Required)

What caused your Pain?(Required)

Have you been treated by a pain management specialist before?(Required)

Yes

No

Are you currently receiving psychological care?(Required)

Yes

No

Have you received addiction care in the past?(Required)

Yes

No

Have you been treated for this pain, if so, what treatments have you received?

Acupuncture

Surgery

Occupational Therapy

Physical Therapy

Chiropractic Care

Spinal Cord Stimulator

Medication Management

Epidural Steroid Injection

Narcotics/Opiates

Trigger Point Injections

Nerve Blocks

Radiofrequency Ablation

Other

What other treatments have you received?(Required)

How would you describe your pain?

Aching

Lightning shock

Stabbing

Burning

Pressure

Terrifying

Cramping

Radiating

Throbbing

Cutting

Sharp

Tight

Dull

Shooting

Tingling

Hot

Soreness

Other

Describe your pain-(Required)

On a scale of 0-10, please select the LOWEST number that your pain has been and the HIGHEST number that your pain has been. (0 is no pain and 10 is the worst possible pain imaginable)(Required)

0

1

2

3

4

5

6

7

8

9

10

On a scale of 0-10, select the number(s) that represent the lowest pain level that you feel is tolerable for yourself. (0 is no pain and 10 is the worst possible pain imaginable)(Required)

0

1

2

3

4

5

6

7

8

9

10

What do you expect from your treatment at Harbor Interventional Pain Center?(Required)

If your pain were to improve, what would you like to gain more of?(Required)

Factors that affect your pain:

Indicate the effect that each item below has on your pain. Select one choice for each item:

Alcohol(Required)

Decreased Pain

Increased Pain

No Effect

Heat(Required)

Decreased Pain

Increased Pain

No Effect

Cold(Required)

Decreased Pain

Increased Pain

No Effect

Walking(Required)

Decreased Pain

Increased Pain

No Effect

Standing(Required)

Decreased Pain

Increased Pain

No Effect

Sitting(Required)

Decreased Pain

Increased Pain

No Effect

Lying down(Required)

Decreased Pain

Increased Pain

No Effect

Bending backward(Required)

Decreased Pain

Increased Pain

No Effect

Riding in a car(Required)

Decreased Pain

Increased Pain

No Effect

Weather changes(Required)

Decreased Pain

Increased Pain

No Effect

Exercise (mild)(Required)

Decreased Pain

Increased Pain

No Effect

Bowel movement(Required)

Decreased Pain

Increased Pain

No Effect

Lifting(Required)

Decreased Pain

Increased Pain

No Effect

Emotional stress(Required)

Decreased Pain

Increased Pain

No Effect

Coughing(Required)

Decreased Pain

Increased Pain

No Effect

Sneezing(Required)

Decreased Pain

Increased Pain

No Effect

What hobbies or recreational activities do you enjoy?(Required)

Are there major concerns or stressors are you and your family experiencing as a result of your pain?(Required)

Do you have difficulty sleeping at night?(Required)

Yes

No

Does the pain frequently wake you up at night?(Required)

Yes

No

Do you take medication to sleep?(Required)

Yes

No

What medication do you take?(Required)

Do you smoke?(Required)

Yes

No

How much?(Required)

Do you drink alcohol?(Required)

Yes

No

How much?(Required)

Do you use any other drugs/or substances?(Required)

Yes

No

Please explain-(Required)

Medical history (Select all that applies)

Alchohol/Drug use

Allergies (environmental)

Anemia

Anxiety

Arthritis (Rheumatoid)

Arthritis (Osteoarthritis)

Asthma

Bladder Problems

Blood Clot History

Cancer

Coronary Artery Disease

Depression

Diabetes

Emphysema/COPD

History of Fracture(s)

Heart Attack

Hepatitis/Liver Disease

High Blood Pressure

High Colesterol

Kidney Disease/Failure

Migraine Headaches

Osteoporosis

Seizure Disorder/Epilepsy

Skin: Psoriasis/Eczema

Sleep Apnea/OSA

CRPS

Stroke

Hyperthyroidisim

Hypothyroidisim

Vascular Disease

Vision Problems

Hearing Difficulty

Medications

Medication

Dosage

How many times a day

 

Add Remove

Please list all current medications including dosage and how many times a day it is taken.

Medication Allergies

Medication

Reaction

 

Add Remove

Please list all current medications including dosage and how many times a day it is taken.

Past Surgical History

Please list any surgeries that you have had, including the date

Family Medical history (Select all that applies)

Alchohol/Drug use

Allergies (environmental)

Anemia

Anxiety

Arthritis (Rheumatoid)

Arthritis (Osteoarthritis)

Asthma

Bladder Problems

Blood Clot History

Cancer

Coronary Artery Disease

Depression

Diabetes

Emphysema/COPD

History of Fracture(s)

Heart Attack

Hepatitis/Liver Disease

High Blood Pressure

High Colesterol

Kidney Disease/Failure

Migraine Headaches

Osteoporosis

Seizure Disorder/Epilepsy

Skin: Psoriasis/Eczema

Sleep Apnea/OSA

CRPS

Stroke

Hyperthyroidisim

Hypothyroidisim

Vascular Disease

Vision Problems

Hearing Difficulty

Please note: it is the patient’s responsibility to contact their insurance provider to verify if their insurance provider requires a specialist referral to be seen at Harbor Interventional Pain Center. In some cases, insurance providers will refuse payment for services when the proper referral process is not followed. Not following this process can result in the patient being financially responsible for services rendered at Harbor Interventional Pain Center.

Radiologic studies

I agree to have radiologic studies forwarded to Harbor Interventional Pain Center.

I do not have radiologic studies that can be forwarded to Harbor Interventional Pain Center.

Consent(Required)

I have completed the questionnaire above to the best of my ability. I have read and understand that it is my responsibility to verify with my insurance provider if a specialist referral is needed before my appointment is scheduled at Harbor Interventional Pain Center.

Patient Signature(Required)

Parent/Legal Guardian Signature(Required)

Date(Required)

MM slash DD slash YYYY

Submit