Step 1 of 8 - Demographics & Contacts 12% EmailThis field is for validation purposes and should be left unchanged.Name(Required) First Last Address(Required) Street Address City State / ProvinceAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is your mailing address different than your physical address?(Required) Yes, my mailing address if different No, my mailing address is NOT different Mailing Address (If different than physical address)(Required)Mailing Address (If different than physical address) Street Address City State / Province / Region ZIP / Postal Code Sex:(Required) Male Female Transgender Marital Status:(Required)Marital StatusSingleDivorcedMarriedPartneredWidowedLegally SeparatedOtherD.O.B(Required)Race:(Required)RaceAmerican IndianAsianNative HawaiianBlack or African AmericanWhiteHispanicOther RaceLanguage:(Required)LanguageEnglishSpanishFrenchGermanEmployer:(Required)Occupation:(Required)Home Phone:(Required)Preferred Number: Cell Phone:(Required)Preferred Number: Work Phone:May we leave personal/medical information on your voicemails? Yes No Email:(Required) Last Four of Your SSN:(Required) Self Pay Yes No INSURANCE COVERAGE: Primary Insurance: Carrier(Required)ID#:(Required)Group#:(Required)Primary Card Holder:(Required) Self Spouse/Partner Other Name of Insured:(Required)Insured's DOB:(Required)Do you have Secondary Insurance? Yes, I have Secondary Insurance No, I DO NOT have Secondary Insurance Secondary Insurance Name:ID#:Group#:Secondary Card Holder: Self Spouse/Partner Other Name of Insured:Insured's DOB:EMERGENCY CONTACTS Primary Emergency Contact(Required) I authorize I do NOT authorize the disclosure of my protected health information (PHI) to the person listed as my Primary Emergency Contact.Secondary Emergency Contact I authorize I do NOT authorize the disclosure of my protected health information (PHI) to the person listed as my Primary Emergency Contact.Name:(Required)Name:Phone Number:(Required)Phone Number:Relationship:(Required)Relationship:SpousePartnerSiblingParentChildFriendOtherRelationship:Relationship:SpousePartnerSiblingParentChildFriendOtherCIRCLE OF CAREReferring Provider:Phone Number:Primary Care Provider:Phone Number:Cardiologist:Phone Number:Oncologist:Phone Number:Pain Management:Phone Number:HOW DID YOU HEAR ABOUT US?HOW DID YOU HEAR ABOUT US?Physician/Provider ReferralFamily or FriendWebsite or Search EngineOtherPHARMACYName:Phone:Fax:Address Street Address City State / Province / Region ZIP / Postal Code NO KNOWN DRUG ALLERGIES: No Known Drug Allergies MEDICATION ALLERGIES: If none, type NONE(Required)Are you allergic to any of the following: Latex Adhesives Contrast CURRENT MEDICATIONSPrescriptionsPrescription NameDoseFrequencyReason Prescribed Add Remove REVIEW OF SYMPTOMSSymptoms:(Required)Do you currently have any of the following symptoms?(Within the last 6 months) NO ISSUES Anxiety Back Pain Burning w/Urination Chest Pain Cough Depression Diarrhea Easy bleeding Easy bruising Fever Headaches Irregular Heartbeat Joint Pain Morning Stiffness Rash Seizures Shortness of Breath Sore Throat Swelling Ulcers/Lesions Wheezing PERSONAL HISTORY Please check boxes below if you have been diagnosed with any of the following medical conditions(Required) NO ISSUES Anemia Anxiety Disorder(s) Asthma Cancer Coagulation Defects Colitis Depression Diabetes Type I Diabetes Type II DVT (Blood Clots) Epilepsy/Seizures Heart Disease Hepatitis High Blood Pressure HIV Kidney Disease Low Blood Pressure Lung Disease Lupus Osteoarthritis Rheumatoid Sleep Apnea Stomach Ulcers Stroke FAMILY HISTORY(Required)Please check boxes if you have been diagnosed with any of the following medical conditions. NO ISSUES Anemia Anxiety Disorder(s) Asthma Cancer Coagulation Defects Colitis Depression Diabetes Type I Diabetes Type II DVT (Blood Clots) Epilepsy/Seizures Heart Disease Hepatitis High Blood Pressure HIV Kidney Disease Low Blood Pressure Lung Disease Lupus Osteoarthritis Rheumatoid Sleep Apnea Stomach Ulcers Stroke SOCIAL HISTORYHeight feet(Required)Please enter a number from 4 to 6.Height Inches(Required)Please enter a number from 1 to 11.Weight(Required)Please enter a number from 90 to 400.Right or Left Handed: Right Left Both Advanced DirectiveDo you have a living will?(Required) Yes No Do you have a DNR (Do Not Resuscitate)?(Required) Yes No Blood Products/TransfusionsDo you have any objections to receiving blood or blood products?(Required) Yes No Vaccination InformationHave you had a flu shot?(Required) Yes No If YES, when was your last shot? MM slash DD slash YYYY If over 65, have you had a pneumonia vaccine?(Required) Yes No If YES, when was your last shot? MM slash DD slash YYYY Do you have a pacemaker?(Required) Yes No If YES, do you take a Beta Blocker?(Required) Yes No Fall: Risk AssessmentIf over 65, have you had any falls in the past year?(Required) Yes No If YES, please check one of the following about your fall: One fall with injury in the past year Two or more falls with injury in the past year One fall without injury in the past year Two or more falls without injury in the past year Smoking/Tobacco HistoryDo you currently smoke?(Required) Yes No If YES, how often and how much?Have you ever smoked?(Required) No Yes If YES, how often and how much?(Required)When did you quit?(Required) MM slash DD slash YYYY What type of tobacco do you smoke?(Required) Cigarettes Cigars Pipe Snuff Vape Alcohol UseDo you currently drink alcohol?(Required) Yes No If YES, what type of alcohol consumed in the past year Beer Wine Liquor If YES, how often did you have an alcoholic drink in the last year?(Required) Never Monthly or less 2 to 4 times a month 2 to 3 times a week Daily or almost daily Declined to specify If YES, how many drinks did you have on a typical day when you drank in the past year?(Required) 1 to 2 drinks 3 to 4 drinks 5 to 6 drinks 7 to 9 drinks 10 or more drinks Declined to specify If YES, how often did you have 6 or more drinks on one occasion in the past year?(Required) Never Less than monthly 2 to 4 times a month 2 to 3 times per week 4 or more times a week Declined to specify Drug UsageDo you now or have you ever used recreational drugs?(Required) Yes No If yes, please explain:Prior Surgeries / Please list Month & Year performed(Required) Add RemovePrior Hospitalizations (Location & Why) Add Remove REASON FOR VISIT(Required) New Patient Second Opinion Established Patient with New Symptoms Patient Symptoms:CONSERVATIVE THERAPY *Your insurance may require conservative therapy before approving surgery. The following information will help with the approval of any diagnostic test to be ordered or surgery if needed* Have you had to use a:(Required) Cane Wheelchair Walker None Have you tried:(Required) Heat Ice Home Exercises Massage Nothing Diagnostic Imaging: (Within a year from your Appointment Date)(Required) Yes I have had some imaging No Current Imaging Have you had any Radiology Imaging (X-Ray, CT, and/or MRI)?(Required) Yes No X-Ray Cervical Thoracic Lumbar Other X-ray Facility/Location(Required)CT Cervical Thoracic Lumbar Brain Other CT Facility/Location(Required)MRI Cervical Thoracic Lumbar Brain Other MRI Facility/Location(Required)Medications(Required) Yes No Type:(Required) NSAID(s) Steroid(s) Muscle Relaxer(s) Anti-Inflammatory(s) Pain Medications Physical Therapy(Required) Yes No Location:Chiropractic Care(Required) Yes No Physician Name:Pain Management(Required) Yes No Physician Name:Epidural Steroid Injections(Required) Yes No Type: Cervical Thoracic Lumbar Lumbar Facet Injections:(Required) Yes No Other Procedure(s) or Treatment(s):Have you missed work for this condition?(Required) Yes No How long have you experienced this pain?(Required)Please indicate your pain level now:(Required) No Pain 1 2 3 4 5 6 7 8 9 10 PHYSICIAN ONLY SECTION I have reviewed the listed ROS/PFSH/Screening with the patient and noted the positive/negative findings for the visit.M.D. Signature:Date MM slash DD slash YYYY BARNETT SPINE ACKNOWLEDGEMENT FORMAuthorize: BARNETT SPINE ACKNOWLEDGEMENT FORM I consent to receive the following documents electronically which are available through our website, unless I request a non-electronic paper copy of the documents disclosed herein. Barnett Spine’s Notice of HIPAA Privacy Practices Barnett Spine’s Financial Policy Barnett Spine’s Medication Policy/Agreement Barnett Spine’s Physician Assistant Information Guide Barnett Spine’s Disclosure of Physician Ownership I authorize: The release of any medical and/or other information necessary to process my claim(s) Payment of medical benefits to my treating physician or supplier for services rendered by Barnett Spine Consent for treatment by my treating physician with Barnett Spine I have read and understand/agree to abide by all the above policies and authorizations of Barnett Spine. Signature(Required)Date(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Number Patient Information Intake Form Step 1 of 8 - Demographics & Contacts 12% InstagramThis field is for validation purposes and should be left unchanged.Name(Required) First Last Address(Required) Street Address City State / ProvinceAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is your mailing address different than your physical address?(Required) Yes, my mailing address if different No, my mailing address is NOT different Mailing Address (If different than physical address)(Required)Mailing Address (If different than physical address) Street Address City State / Province / Region ZIP / Postal Code Sex:(Required) Male Female Transgender Marital Status:(Required)Marital StatusSingleDivorcedMarriedPartneredWidowedLegally SeparatedOtherD.O.B(Required)Race:(Required)RaceAmerican IndianAsianNative HawaiianBlack or African AmericanWhiteHispanicOther RaceLanguage:(Required)LanguageEnglishSpanishFrenchGermanEmployer:(Required)Occupation:(Required)Home Phone:(Required)Preferred Number: Cell Phone:(Required)Preferred Number: Work Phone:May we leave personal/medical information on your voicemails? Yes No Email:(Required) Last Four of Your SSN:(Required) Self Pay Yes No INSURANCE COVERAGE: Primary Insurance: Carrier(Required)ID#:(Required)Group#:(Required)Primary Card Holder:(Required) Self Spouse/Partner Other Name of Insured:(Required)Insured's DOB:(Required)Do you have Secondary Insurance? Yes, I have Secondary Insurance No, I DO NOT have Secondary Insurance Secondary Insurance Name:ID#:Group#:Secondary Card Holder: Self Spouse/Partner Other Name of Insured:Insured's DOB:EMERGENCY CONTACTS Primary Emergency Contact(Required) I authorize I do NOT authorize the disclosure of my protected health information (PHI) to the person listed as my Primary Emergency Contact.Secondary Emergency Contact I authorize I do NOT authorize the disclosure of my protected health information (PHI) to the person listed as my Primary Emergency Contact.Name:(Required)Name:Phone Number:(Required)Phone Number:Relationship:(Required)Relationship:SpousePartnerSiblingParentChildFriendOtherRelationship:Relationship:SpousePartnerSiblingParentChildFriendOtherCIRCLE OF CAREReferring Provider:Phone Number:Primary Care Provider:Phone Number:Cardiologist:Phone Number:Oncologist:Phone Number:Pain Management:Phone Number:HOW DID YOU HEAR ABOUT US?HOW DID YOU HEAR ABOUT US?Physician/Provider ReferralFamily or FriendWebsite or Search EngineOtherPHARMACYName:Phone:Fax:Address Street Address City State / Province / Region ZIP / Postal Code NO KNOWN DRUG ALLERGIES: No Known Drug Allergies MEDICATION ALLERGIES: If none, type NONE(Required)Are you allergic to any of the following: Latex Adhesives Contrast CURRENT MEDICATIONSPrescriptionsPrescription NameDoseFrequencyReason Prescribed Add Remove REVIEW OF SYMPTOMSSymptoms:(Required)Do you currently have any of the following symptoms?(Within the last 6 months) NO ISSUES Anxiety Back Pain Burning w/Urination Chest Pain Cough Depression Diarrhea Easy bleeding Easy bruising Fever Headaches Irregular Heartbeat Joint Pain Morning Stiffness Rash Seizures Shortness of Breath Sore Throat Swelling Ulcers/Lesions Wheezing PERSONAL HISTORY Please check boxes below if you have been diagnosed with any of the following medical conditions(Required) NO ISSUES Anemia Anxiety Disorder(s) Asthma Cancer Coagulation Defects Colitis Depression Diabetes Type I Diabetes Type II DVT (Blood Clots) Epilepsy/Seizures Heart Disease Hepatitis High Blood Pressure HIV Kidney Disease Low Blood Pressure Lung Disease Lupus Osteoarthritis Rheumatoid Sleep Apnea Stomach Ulcers Stroke FAMILY HISTORY(Required)Please check boxes if you have been diagnosed with any of the following medical conditions. NO ISSUES Anemia Anxiety Disorder(s) Asthma Cancer Coagulation Defects Colitis Depression Diabetes Type I Diabetes Type II DVT (Blood Clots) Epilepsy/Seizures Heart Disease Hepatitis High Blood Pressure HIV Kidney Disease Low Blood Pressure Lung Disease Lupus Osteoarthritis Rheumatoid Sleep Apnea Stomach Ulcers Stroke SOCIAL HISTORYHeight feet(Required)Please enter a number from 4 to 6.Height Inches(Required)Please enter a number from 1 to 11.Weight(Required)Please enter a number from 90 to 400.Right or Left Handed: Right Left Both Advanced DirectiveDo you have a living will?(Required) Yes No Do you have a DNR (Do Not Resuscitate)?(Required) Yes No Blood Products/TransfusionsDo you have any objections to receiving blood or blood products?(Required) Yes No Vaccination InformationHave you had a flu shot?(Required) Yes No If YES, when was your last shot? MM slash DD slash YYYY If over 65, have you had a pneumonia vaccine?(Required) Yes No If YES, when was your last shot? MM slash DD slash YYYY Do you have a pacemaker?(Required) Yes No If YES, do you take a Beta Blocker?(Required) Yes No Fall: Risk AssessmentIf over 65, have you had any falls in the past year?(Required) Yes No If YES, please check one of the following about your fall: One fall with injury in the past year Two or more falls with injury in the past year One fall without injury in the past year Two or more falls without injury in the past year Smoking/Tobacco HistoryDo you currently smoke?(Required) Yes No If YES, how often and how much?Have you ever smoked?(Required) No Yes If YES, how often and how much?(Required)When did you quit?(Required) MM slash DD slash YYYY What type of tobacco do you smoke?(Required) Cigarettes Cigars Pipe Snuff Vape Alcohol UseDo you currently drink alcohol?(Required) Yes No If YES, what type of alcohol consumed in the past year Beer Wine Liquor If YES, how often did you have an alcoholic drink in the last year?(Required) Never Monthly or less 2 to 4 times a month 2 to 3 times a week Daily or almost daily Declined to specify If YES, how many drinks did you have on a typical day when you drank in the past year?(Required) 1 to 2 drinks 3 to 4 drinks 5 to 6 drinks 7 to 9 drinks 10 or more drinks Declined to specify If YES, how often did you have 6 or more drinks on one occasion in the past year?(Required) Never Less than monthly 2 to 4 times a month 2 to 3 times per week 4 or more times a week Declined to specify Drug UsageDo you now or have you ever used recreational drugs?(Required) Yes No If yes, please explain:Prior Surgeries / Please list Month & Year performed(Required) Add RemovePrior Hospitalizations (Location & Why) Add Remove REASON FOR VISIT(Required) New Patient Second Opinion Established Patient with New Symptoms Patient Symptoms:CONSERVATIVE THERAPY *Your insurance may require conservative therapy before approving surgery. The following information will help with the approval of any diagnostic test to be ordered or surgery if needed* Have you had to use a:(Required) Cane Wheelchair Walker None Have you tried:(Required) Heat Ice Home Exercises Massage Nothing Diagnostic Imaging: (Within a year from your Appointment Date)(Required) Yes I have had some imaging No Current Imaging Have you had any Radiology Imaging (X-Ray, CT, and/or MRI)?(Required) Yes No X-Ray Cervical Thoracic Lumbar Other X-ray Facility/Location(Required)CT Cervical Thoracic Lumbar Brain Other CT Facility/Location(Required)MRI Cervical Thoracic Lumbar Brain Other MRI Facility/Location(Required)Medications(Required) Yes No Type:(Required) NSAID(s) Steroid(s) Muscle Relaxer(s) Anti-Inflammatory(s) Pain Medications Physical Therapy(Required) Yes No Location:Chiropractic Care(Required) Yes No Physician Name:Pain Management(Required) Yes No Physician Name:Epidural Steroid Injections(Required) Yes No Type: Cervical Thoracic Lumbar Lumbar Facet Injections:(Required) Yes No Other Procedure(s) or Treatment(s):Have you missed work for this condition?(Required) Yes No How long have you experienced this pain?(Required)Please indicate your pain level now:(Required) No Pain 1 2 3 4 5 6 7 8 9 10 PHYSICIAN ONLY SECTION I have reviewed the listed ROS/PFSH/Screening with the patient and noted the positive/negative findings for the visit.M.D. Signature:Date MM slash DD slash YYYY BARNETT SPINE ACKNOWLEDGEMENT FORMAuthorize: BARNETT SPINE ACKNOWLEDGEMENT FORM I consent to receive the following documents electronically which are available through our website, unless I request a non-electronic paper copy of the documents disclosed herein. Barnett Spine’s Notice of HIPAA Privacy Practices Barnett Spine’s Financial Policy Barnett Spine’s Medication Policy/Agreement Barnett Spine’s Physician Assistant Information Guide Barnett Spine’s Disclosure of Physician Ownership I authorize: The release of any medical and/or other information necessary to process my claim(s) Payment of medical benefits to my treating physician or supplier for services rendered by Barnett Spine Consent for treatment by my treating physician with Barnett Spine I have read and understand/agree to abide by all the above policies and authorizations of Barnett Spine. Signature(Required)Date(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Number
