New Patient Form



  • Family Medical History: Please list any outstanding medical conditions:

  • REVIEW OF SYSTEMS: Please select if you have or had any of the following:

  • 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.
  • 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.