Intake Form Name(Required)Date of Birth(Required) MM slash DD slash YYYY Sex(Required)SSN(Required)Home PhoneWork PhoneMobile PhoneEmail Address(Required)City(Required)State(Required)Zip(Required)Language(Required)Emergency ContactEmergency Contact PhonePrimary Care Provider(Required)Referring ProvidersHow tall are you?(Required)How much do you weigh?(Required)Name of EmployerName of Attorney(Please enter N/A, if you have not obtained an attorney)Where did you have your MRI/CT or X-RaysWhat was the date? MM slash DD slash YYYY Please ensure that your imaging has been sent to us (2780 Snelling Avenue N, Suite 310, Roseville, MN 55113) on a disc along with the radiology report, if you have not already done so.Do you have any allergies, if so, what?(Required)Do you regularly take any blood thinning medications, nerve medication or narcotics?(Required) No Yes Do you have a pacemaker, stent, any cardiovascular heart conditions, diabetes, uncontrolled high blood pressure or any other health condition that we should be aware of? If so, what?(Required)Do you have any mental health conditions, diagnosed or undiagnosed? If so, are you under the care of a mental health provider?(Required)Are you a smoker?(Required) No Yes Past Smoke: When was your quit date? MM slash DD slash YYYY Primary Insurance InformationCarrier(Required)Carrier Address(Required)Policy #(Required)Carrier Phone Number(Required)Group ID/Name(Required)Secondary Insurance InformationCarrierCarrier AddressPolicy #Carrier Phone NumberGroup ID/NameIs this related to a Work Comp Injury? No Yes Workers CompCarrier(Required)Date of Injury(Required) MM slash DD slash YYYY Claim #(Required)Employer(Required)Adjusters Name(Required)Adjusters Phone(Required)Is this related to a Auto Accident? No Yes Auto PIP BenefitsCarrier(Required)Date of Injury(Required) MM slash DD slash YYYY Claim #(Required)Adjusters Name(Required)Adjusters Phone(Required)SymptomsSymptom type I have thoracic or lumbar spine symptoms I have cervical spine symptoms Lumbar Spine SymptomsOn a scale 1-10, what is your pain level on a good day?On a Bad day?How long have you had your pain?How did your symptoms start? insidious onset beginning after surgery having chronic back pain previous episodes of sciatica falling from a height occurred when lifting an object playing a sport slipping and falling trauma tripping on an uneven surface being involved in a motor vehicle accident other injury at work If injury at workWhich describe your symptoms? aching pins and needle-like sensations associated with shooting sensations stiffness burning cramp-like dull radiating to above the left knee radiating to above the right knee radiating to below the left knee radiating to below the right knee radiating to left foot radiating to right foot sharp stabbing worse with ambulation worse with extension worse with flexion worse with weight bearing other Timing constant intermittent occurs intermittently worse after activity worse at the end of the day worse during activity worse during the day worse during the night worse in the morning other Associated Symptoms Left pain on the left of back numbness in left lower leg pain in the left buttock pain in the left front thigh pain in the left outside thigh pain in the left inside thigh pain in the left back of thigh tingling in left lower extremity weakness in left lower extremity Associated Symptoms Right pain on the right of back numbness in right lower leg pain in the right buttock pain in the right front thigh pain in the right outside thigh pain in the right inside thigh pain in the right back of thigh tingling in right lower extremity weakness in right lower extremity What makes it worse? all movement bending over exercise lifting objects lying flat standing for prolonged periods walking for long distances other Do you have a history of the following? previous disc herniation prior history of spine surgery recurrent back pain rheumatoid arthritis scoliosis spinal stenosis Do you experience any of the following? bowel incontinence urinary incontinence What treatments have you tried? no treatment anti-inflammatories Tylenol muscle relaxants oral steroids hydrocodone oxycodone prescription pain medication activity modification brace physical therapy chiropractic treatments pilates weight reduction yoga epidural steroid injection facet joint injection other What procedures have you had for this problem? no procedures cementoplasty chiropractic manipulation decompression discectomy epidural steroid injection facet joint injection fusion, anterior laminectomy microdiscectomy injection ORIF spine fracture spinal cord stimulator other Cervical SymptomsHow long have you had your painWhere is your pain located? Upper Neck Pain Mid Neck Pain Lower Neck Pain What is your hand dominance? ambidextrous left hand dominant no dominance right hand dominant What best describes your pain? associated with aching associated with burning chronic constant cramp‐like dull intermittent painful radiating into both hands radiating into the left hand radiating into the right hand sharp shooting down the arms shooting into the shoulder region stabbing tender to touch How did your pain begin? an insidious onset being involved in motor vehicle accident falling from a height having chronic neck pain injury at work lifting an object playing a sport slipping and falling trauma tripping on an uneven surface other What are you currently using to treat your pain? acupuncture activity modification Advil Aleve aspirin Bayer capsaicin cream Celebrex cervical collar chiropractic adjustment epidural steroid injection facet joint injection Flexeril ibuprofen massage Medrol dose pack Mobic Motrin Naproxen neck brace physical therapy pilates Skelaxin Soma Toradol traction Tylenol Tylenol with codeine Ultram weight reduction yoga other What aggravates or alleviates your pain? improves with pain medication improves with physical therapy improves with rest improves with stretching worsens with bending worsens with exercise worsens with lifting worsens with neck movement worse with activity worse with sitting worse with standing other Do you experience any of the following: bowel incontinence urinary incontinence (not associated with stress incontinence) upper extremity numbness upper extremity tingling upper extremity weakness What procedures have you had? laminectomy microdiscectomy spinal fusion disc replacement Skip back to main navigation
