Patient Intake Forms
New England Health and Wellness LLC
Patient Information:
Date:
Name:
DOB:
Address:
City:
State:
Zip:
Email:
SSN:
Phone:
Cell:
Chief Complaint:
□ Numbness & Pain In Hands
□ Numbness & Pain in Feet
□ Difficulty Keeping Balance
□ Neuropathy of Hands or Feet
How did your Neuropathy Begin?
□ Diabetes
□ Chemo-Therapy
□ Back Surgery
□ Heart Surgery
□ Neck Surgery
□ Radiation Therapy
□ Cholesterol Lowering Medication
Medical Providers:
Primary Dr.
Phone #
Diabetes Dr.
Phone #
Heart Dr.
Do You have Pain at Night?
□ YES
□ NO
Has your weight increased or
decreased Substantially in the last
year?
Insurance Company:
□ Medicare
□ YES
□ NO
□ Blue Cross/Blue Shield
□ Tufts
Where Exactly is the pain/numbness?
□ Aetna
□ Tips of fingers
□ Fingers
□ Harvard Pilgrim
□ Palms of hands □ Back of hands
□ Medicaid (Mass Health)
□ Wrist
□ Forearm
□ Cigna
□ Toes
□ Other__________________________ □ Tip Of Toes
□ Bottom of Feet □ Top of Foot
□ Ankle
□ Shin
Patient Statistics:
□ Calf
□ Knee
Height
□ Thigh
Weight
1
Patient Intake Forms
New England Health and Wellness LLC
How long have you had this condition?
□ Days _________
□ Weeks _______
□ Months _______
□ Years _________
□ More than 5 Years?
□ More than 10 Years?
□ More than 20 Years?
What makes your Pain Better?
□ Cold
□ Heat
□ TENS
□ Physical Therapy
□ Neurotin
□ Lyrica
□ Cymbalta
□ Other _________________________
Do you have Muscle weakness?
□YES
□ NO
Recent History:
Flu, Cold, Bites
Tobacco Use
Alcohol Use
Infections
Which Muscle is Weak Specifically?
________________________________
Do you experience Muscle Spasms?
□YES
□ NO
□ YES
□ YES
□ YES
□ YES
□ NO
□ NO
□ NO
□ NO
□ YES
□ YES
□ NO
□ NO
□
□
□
□
□
□
□
□
YES
YES
YES
YES
YES
YES
YES
YES
□
□
□
□
□
□
□
□
NO
NO
NO
NO
NO
NO
NO
NO
Medical Conditions: Current
Pacemaker
□ YES
High Blood Pressure
□ YES
HIV
□ YES
Diabetes
□ YES
Cancer
□ YES
Heart Condition
□ YES
Emphysema
□ YES
Kidney Failure
□ YES
Anemia
□ YES
Arthritis
□ YES
Depression
□ YES
Dementia
□ YES
Other
□ YES
□
□
□
□
□
□
□
□
□
□
□
□
□
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
Prior Treatment:
Physical Therapy
Trigger Point
Injections
Epi-Dural Injections
Facet Blocks
Chiropractic
TENS
Nerve Blocks
Neurontin
Lyrica
Cymbalta
Overall, your condition is:
□ Getting better
□ Staying the same
□ Worsening
What type of Pain do you have?
□ Shooting Pain
□ Radiating Pain
□ Dull Pain
□ Constant Pain
□ Sharp Pain
□ Intermittent Pain
□ Burning Pain
How Would you Rate your Pain on a scale of
1-10 (with 10 being Severe PAIN)?
□1 □2 □3 □4 □ 5 □6 □7 □8 □9 □10
What makes your Pain worse?
□ Walking
□ Sleeping
□ Rest
□ Bending
□ Sitting
□ Driving
□ Working
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Patient Intake Forms
New England Health and Wellness LLC
Drug Allergies: (Please circle)
□ Penicillin
□ Latex
□ Amoxicillin
□ Marcaine
□ Lidocaine
□ Solumedrol
□ Cortisone
□ Iodine
Past Medical History:
Lost Consciousness
Injured Head/Neck
Had Severe
Headache
Had a Seizure
Had a Stroke
Had a Brain Tumor
Blood Clotting
Disorder
Surgical Disorder:
Low back Surgery
Mid Back Surgery
Neck Surgery
Prostate Surgery
Appendectomy
Gallbladder Surgery
Hysterectomy
Cardiac Bypass
□ YES
□ YES
□ YES
□ NO
□ NO
□ NO
□
□
□
□
□
□
□
□
YES
YES
YES
YES
□ YES
□ YES
□ YES
□ YES
□ YES
□ YES
□ YES
□ YES
Comments for the Doctor:
NO
NO
NO
NO
Other Medical History:
3
□
□
□
□
□
□
□
□
NO
NO
NO
NO
NO
NO
NO
NO