Utah Pain Specialists

When seeking prior authorization from your insurance or Medicare, the New Patient Questionnaire contains necessary information. Dates of physical therapy, prior treatments/procedures, your health history, are all factors in receiving approval for your procedures. Please be through. Click here to review our Privacy Policy and HIPAA agreement.

First Name

Middle Name

Last Name

Phone Number

Mailing Address

Physical Address

Same as Mailing Different from Mailing

Physical Address

Date of Birth

Emergency Contact

Contact's Phone

Referring Physician

Physician's Phone

Insurance Company

Insurance Phone

Insurance ID Number and Group Number

Why did your referring physician send you to our clinic?

Are you involved in any court cases or lawsuits?

Yes No

Do you have a Workers' Compensation claim?

Yes No

Mark the areas on the image where you are experiencing symptoms

My pain is

Continuous (no flares) Continuous (with flares) Intermittent (with flares)

When does your pain flare

Morning Afternoon Evening Night

Was there an event that started your pain?

When did your pain start?

List activities that worsen your pain

List activities that improve your pain

Mark all activities that you cannot do because of pain.

Bending

Exercising

Lifting

Sitting

Walking

Standing

Gardening

Housework

During the past month, have you felt down, blue, depressed or hopeless due to pain?

Yes No

Have you ever felt like harming yourself?

Yes No

Have you ever felt like harming anyone else?

Yes No

Have you ever had a suicide attempt

Yes No

Do you have panic attacks

Yes No

Are you working?

Yes No

How many hours are you working?

List all current medications and doses

Please indicate if you are allergic to any of the following:

Latex

Iodine

Medical Adhesives (tapes, bandaids)

Topical Antibiotics (Neosporin)

Antibiotics (Penicillian)

List any medication allergies and their reactions

Do you take any blood thinners (Coumadin, Plavix, Lovenox, Eliquis, Heparin, Xarelto, Pradaxa, Brilinta, Effient)

Yes No

Do you take any medicines that contain Tylenol or Acetaminophen?

Yes No

List all other medical problems (high blood pressure, diabetes, asthma, etc.)

List all past surgeries and the dates

List any previous pain injections/procedures tried, and the dates

List the medical problems that run in your family, include the familial relationship

List dates of previous physical therapy appointments

Indicate all other therapies used to relieve your pain

Physical Therapy

Massage Therapy

Chiropractic Acupunture

Chiropractic Adjustment

Epidural Injection

Radio Frequency Rhizotomy

Other Shot

Do you currently use tobacco

Yes No

Indicate which street drugs you have used int he past year

Marijuana

Cocaine

Meth

Heroin

Other

Have you ever finished a prescription earlier than it was prescribed?

Yes No

Have you ever received the same medication from multiple physicians?

Yes No

General Health

Fever

Chills

Night Sweats

Fatigue

Weight Loss

Weakness

Eyes

Change in Vision

Eye Pain

Eye Swelling

Tearing

Ears

Hearing Loss

Ringing

Ear Pain

Discharge

Nose

Nose Bleeds

Discharge

Stuffy Nose

Sinus Problems

Loss of Smell

Throat

Sore Throat

Change in Taste

Discharge

Bad Breath

Dental Cavities

Neck

Stiff Neck

Neck Pain

Whiplash Injury

Heart

Chest Wall Pain

Swollen Ankles

Exercise Intolerance

Fainting

Lungs

Cough

Wheezing

Emphysema

Bronchitis

Coughing Blood

Urinary

Burning

Frequent

Urgent

Stress Incontinence

Kidney Stones

Musculoskeletal

Stiff Joints

Arthritis

Restless Legs at Night

Muscle Spasms

Scoliosis

Sleep

Apnea

Narcolepsy

Insomnia

Poor Sleep

Many trips to the bathroom

Skin

Rash

Eczema

Dry

Itching

Neurological

Numbness

Tingling

Weakness

Tripping

Falling

Headaches

Psychiatric

Claustrophobia

Paranoia

Nightmares

Hearing Voices

Blood

Bleed Easily

Bruise Easily

Using Bloodthinner(s)

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