New Patient Health Questionnaire

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Pain Relief Institute of AmericaNew Patient Health Questionnaire

Patient information

Full nameDate of birthPhoneEmailAddressCity, state, ZIPEmergency contact (name and phone)Primary care physician

Insurance

Insurance companyMember IDGroup numberReferred by (if any)

Current medications

List every prescription, over-the-counter medicine and supplement, with the dose.

MedicationDose and how often

MedicationDose and how often

MedicationDose and how often

MedicationDose and how often

MedicationDose and how often

MedicationDose and how often

Allergies

Medicines, latex, contrast dye, foods (write NONE if none)

Are you allergic to contrast dye, iodine or latex? Yes No

Medical history

Check all that apply.

High blood pressure Heart disease Stroke Diabetes Kidney disease Liver disease Lung disease or sleep apnea Cancer Osteoporosis Arthritis Depression or anxiety Migraines Bleeding problems Infection history Other

Do you take blood thinners (for example warfarin, Eliquis, Xarelto, Plavix, aspirin)? Yes No

If yes, which one and who prescribes it

Are you, or could you be, pregnant? Yes No

Are you currently being treated for an infection? Yes No

Surgeries and hospital stays

ProcedureYear

ProcedureYear

ProcedureYear

Lifestyle

Do you smoke or use tobacco? Yes No

Do you drink alcohol regularly? Yes No

Patient signatureDate