New Patient Forms

New Patient Form

"*" indicates required fields

Gender
Dominant Hand
Pain Score 1 - 10
Quality of Pain: (please choose all that apply to your pain)
Front
Back
Does it radiate into your arms?
Does it radiate into your legs?
Does pain in legs decrease when you sit?
Do you sleep well?
Do you fall asleep easily?
Do you wake up easily?
Do you have any numbness?
Do you have any weakness?
Do you have any bladder or bowel incontinence?
Past Treatments:
Radiology Testing
Smoker:
Alcohol:
Recreational Drugs:
Do you have any history of prescription medication Abuse/Overuse
Do you have any history of addiction:
Working status:
Marital Status/Children:

Please select any medical conditions you have been diagnosed with:
If diagnosed with cancer, is it in remission?
Please select if you have any of the following:

Family Medical History: Please list any outstanding medical conditions:

REVIEW OF SYSTEMS: Please select if you have or had any of the following:
General / Constitutional
Eyes
Ears, Nose, Throat
Cardiovascular
Pulmonary
Gastrointestinal
Genitourinary
Musculoskeletal
Skin
Neurologic
Endocrine
Hematologic / Lymphatic
Infectious Diseases
Gynecologic

IT IS SEGURA NEUROSCIENCE AND PAIN CENTER'S PRACTICE NOT TO PRESCRIBE BENZODIAZEPINES (XANAX, ATIVAN, VALIUM, KLONOPIN) AND SOMA. BY CHECKING BELOW YOU ACKNOWLEDGE THAT YOU UNDERSTAND AND ARE AWARE THAT EXTREME SLEEPINESS, RESPIRATORY DEPRESSION, COMA, AND DEATH CAN OCCUR WITH THE USE OF THESE MEDICATIONS AT THE SAME TIME.

Clinical guidelines from the U.S. Centers for Disease Control and Prevention (CDC) and existing labeling warnings regarding combined use caution prescribers about co-prescribing opiods and benzodiazepines to avoid potential serious health outcomes. The actions of the FDA today are consistent with the CDC.
There are dangers of certain medication interactions with chronic opioid use.*
COMM
Please answer each question as honestly as possible. Keep in mind that we are only asking about the past thirty days. There are no right or wrong answers. If you are unsure about how to answer the question, please give the best answer you can.
1. In the past 30 days, how often have you had trouble with thinking clearly or had memory problems?
2. In the past 30 days, how often do people complain that you are not completing necessary tasks? (i.e., doing things that need to be done, such as going to class, work, or appointments)
3. In the past 30 days, how often have you had to go to someone other than your prescribing physician to get sufficient pain relief from medications? (i.e., another doctor, the Emergency Room, friends, street sources)
4. In the past 30 days, how often have you taken your medications differently from how they are prescribed?
5. In the past 30 days, how often have you seriously thought about hurting yourself?
6. In the past 30 days, how much of your time was spent thinking about opiod medications (having enough, taking them, dosing schedule, etc.)?
7. In the past 30 days, how often have you been in an argument?
8. In the past 30 days, how often have you had trouble controlling your anger (e.g., road rage, screaming, etc.)?
9. In the past 30 days, how often have you needed to take pain medications belonging to someone else?
10. In the past 30 days, how often have you been worried about how you're handling your medications?
11. In the past 30 days, how often have others been worried about how you're handling your medications?
12. In the past 30 days, how often have had to make an emergency phone call or show up at the clinic without an appointment?
13. In the past 30 days, how often have you gotten angry at people?
14. In the past 30 days, how often have you had to take more of your medication than prescribed?
15. In the past 30 days, how often have you borrowed pain medication from someone else?
16. In the past 30 days, how often have you used your pain medication for symptoms other than for pain (e.g., to help you sleep, improve your mood, or relieve stress)?
17. In the past 30 days, how often have you had to visit the Emergency Room?