PATIENT REGISTRATION FORM
Date ____________________________
PATIENT INFORMATION______________________________________________________________(Please Print)___
□ Dr. □ Mr. □ Mrs. □ Ms. □ Jr. □ Sr. □ Other _________________
Patient’s Name (Last) __________________________ (First) __________________________ (MI) _____
Marital Status □ Married □ Single □ Divorced □ Widowed □ Other _____________________
Social Security Number _______-_____-__________ □ Female □ Male Date of Birth ______/______/________
Phone #s: Home ___________________ □ Day □ Evening Cellular _________________________
Work ___________________ □ Day □ Evening May we contact you at work? □ Yes □ No
Address __________________________________________________________________________ Apt. # ____________
City, State, Zip Code ___________________________________________________________________________________
Employment status □ Employed □ Student □ Retired □ Self-Employed □ Unemployed
Employer ___________________________________________ Occupation _____________________________________
Emergency Contact Name _____________________________________________ Phone Number ____________________
Relationship to Patient __________________________________________________________________________________
PRIMARY INSURANCE INFORMATION_______________________________________________________________
Name of Insured ________________________________________ Relationship to Patient ___________________________
Insurance Company Name ______________________________________ Phone Number ___________________________
Subscriber ID (Policy Number) _______________________ Group ID ____________________
Effective Date _______________ Insured Date of Birth _________________ Insured SS # _______-_____-__________
Address of Insured _____________________________________________________________________________________
SECONDARY INSURANCE INFORMATION____________________________________________________________
Name of Insured ________________________________________ Relationship to Patient ___________________________
Insurance Company Name ______________________________________ Phone Number ___________________________
Subscriber ID (Policy Number) _________________________________ Group ID ________________________________
Effective Date _______________ Insured Date of Birth _________________ Insured SS # _______-_____-__________
Address of Insured _____________________________________________________________________________________
VISIT INFORMATION_______________________________________________________________________________
Reason for Visit ______________________________________________________________________________________
Is this visit the result of an accident?□ Yes □ No Date of Accident ________________________________
If so, choose one: □ Auto □ Worker’s Comp □ Other Accident _______________________________________
Primary Doctor’s Name _______________________________________ City/State _______________________________
How did you hear about Capital Regional Spine Center? □ Physician Referred Me □ Friend
□ Hospital Emergency Room □ Newspaper □ Radio □ TV □ Billboard □ Insurance Company Referred Me
____________________________________________________________________________________________________
I agree that the information supplied on this form is accurate and up-to-date to the best of my knowledge.
Patient (or Responsible Party) Signature ________________________________________ Date ____________________
Name ____________________________ Date _________________
PAIN ASSESSMENT
Mark the figures below with an X to show where you feel pain the most. Use arrows to show if it
moves to other areas of your body.
When did you first notice this problem? ___________________________________________________
Is the problem constant or does it come and go? _____________________________________________
What makes the problem worse? _________________________________________________________
________________________________________________________________________________________________________________
What relieves the problem? ____________________________________________________________
____________________________________________________________________________________
Does the problem interfere with your normal functions? Yes No If yes, please explain ___________
____________________________________________________________________________________
Name _____________________________ Date _________________
INITIAL PATIENT HISTORY
Please list all the conditions for which you have been treated (example: diabetes, high blood pressure,
etc.). _______________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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Please list all the past surgical procedures and the approximate dates they were performed.
____________________________________________________________________________________
____________________________________________________________________________________
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Please list all medications you are taking. Include over the counter medications, vitamins, etc.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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Do you smoke? Yes No If so, how much and for how long? ______________________________
Do you have any allergies (example: medications, foods, latex, etc.) ____________________________
____________________________________________________________________________________
Do you have any of the following?
Back Pain Y N Tingling Y N
Muscle Pain Y N Joint Pain Y N
Neck Pain Y N Numbness Y N