New Nerve Patient Registration Form

First Name *

Last Name *

Date of Birth *

Sex *

Male

Female

Address *

City *

State *

Postal code *

Phone *

May we leave a message? *

Yes

No

Email *

Primary Language *

English

Spanish

Emergency Contact Name *

Emergency Contact Phone *

Primary Care Doctor *

Pharmacy *

Pharmacy Phone *

Name

DOB

Phone

Primary Insurance

Member ID

Secondary Insurance

Member ID

Medication

Medication, Dosage, & How Often Do You Take?
Medication, Dosage, & How Often Do You Take?
Medication, Dosage, & How Often Do You Take?
Medication, Dosage, & How Often Do You Take?
Medication, Dosage, & How Often Do You Take?
Medication, Dosage, & How Often Do You Take?
Medication, Dosage, & How Often Do You Take?
Medication, Dosage, & How Often Do You Take?

Check "Yes" if you would rather provide a list of medications in person. *

Yes

No

Do you have allergies other than seasonal? *

Yes, please list below

No Known Drug

Allergies

Allergy & Reaction
Allergy & Reaction
Allergy & Reaction
Allergy & Reaction
Allergy & Reaction
Allergy & Reaction
Allergy & Reaction

Check "Yes" if you would rather provide a list of allergies in person. *

Yes

No

Smoking Status *

Current Smoker

Former Smoker

Never Smoked

Past Surgeries

Type of Surgery & Date
Type of Surgery & Date
Type of Surgery & Date
Type of Surgery & Date
Type of Surgery & Date
Type of Surgery & Date
Type of Surgery & Date
Type of Surgery

Check "Yes" if you would rather provide a list of past surgeries in person. *

Yes

No

Family History Diabetes *

N/A

Mother

Father

Family History Cancer *

N/A

Mother

Father

Family History Heart Disease *

N/A

Mother

Father

Family History High Blood Pressure *

N/A

Mother

Father

Family History Stroke *

N/A

Mother

Father

Family History Coronary Artery Disease *

N/A

Mother

Father

Family History Thyroid Disorder *

N/A

Mother

Father

Family History Rheumatoid Arthritis *

N/A

Mother

Father

Current Problem *

When did the problem start? *

How did the problem start? *

Suddenly

Gradually

Traumatic

Slowly

Since the problem began has it: *

Stayed the same

Become worse

Got better than worse

Improved

How would you rate your pain on a scale from 1 to 10? *

When was your last A1c? *

What was the result? *

Have you ever had chemotherapy? *

Yes

No

Have you ever been exposed to heavy metals? *

Yes

No

Have you ever been exposed to solvents? *

Yes

No

Did you serve in the military? *

Yes

No

Do you have a history of alcohol abuse? *

Yes

No

Do you have a pacemaker or defibrillator? *

Yes

No

Have you ever had shingles? *

Yes

No

Have you ever had carpal tunnel syndrome? *

Yes

No

Do you have any other neurological conditions? *

Yes

No

Do foods bring on your nerve symptoms? *

Yes

No

Have you ever been diagnosed with Chronic Pain? *

Yes

No

Have you ever been diagnosed with Low back stenosis or herniated disks? *

Yes

No

Have you ever been diagnosed with sciatica or Radiculopathy? *

Yes

No

Have you ever had an NCV/EMG? (needles poking you) *

Yes

No

Have you ever had a nerve skin biopsy? *

Yes

No

How often do you feel pain? *

Occasionally

Intermittently

Nearly Constant

Constantly

Worst: *

Least: *

Average: *

Today: *

Your ability to walk: *

Ability to stand without mobility device: *

Ability to sit: *

Ability to climb stairs: *

Ability to perform daily activities: *

Ability to bathe self: *

Strength and endurance: *

Physical activity: *

Ability to be active without fear of falling: *

Overall energy: *

Self-esteem or self-worth: *

Overall concentration: *

Overall mood: *

Normal work: *

Sleep: *

Family relationship: *

Spousal/Partner relationship: *

Social activities: *

Enjoyment of life: *

Goal 1: *

Goal 2:

Goal 3:

Is there something that you would like to tell Dr. Parker regarding your condition?

Patient Name *

Date *

To the best of my knowledge, I have answered the questions on this form accurately. I understand that providing incorrect information can be dangerous to my health. I understand that it is my responsibility to inform the doctor and office staff of any changes in my medical status. *

Clear

1. Do you experience any pain in your legs or feet while are rest? *

Yes

No

2. Do you have uncomfortable aching, fatigue, tingling, cramping or pain in your feet, calves, buttocks, hip or thigh during walking/exercise? *

Yes

No

3. If yes to Question 2, does the pain go away when you stop walking/exercising? *

Yes

No

4. Do your feet get pale, discolored, or bluish at any time during the day? *

Yes

No

5. Do you have an infection, skin wound or ulcer on your leg or foot that is slow to heal over the past 8-12 weeks? *

Yes

No

6. Are you over the age of 65? *

Yes

No

7. Are you over the age of 50? *

Yes

No

8. Do you have high cholesterol or other blood lipid (fat) problems or require cholesterol medication? *

Yes

No

9. Do you have high blood pressure or take medication to reduce blood pressure? *

Yes

No

10. Do you have diabetes? *

Yes

No

11. Do you have a history of chronic kidney disease? *

Yes

No

12. Do you currently or have you ever smoked? *

Yes

No

13. Do you have a history of stroke or mini stroke (TIA)? *

Yes

No

14. Do you have a history of heart disease (heart attack, MI)? *

Yes

No

15. Do you have a history of carotid stenosis, AAA (abdominal aortic aneurysm), or stent placement? *

Yes

No

Full Name *

Date *

Please List the Locations of your Pain Here: *

"I hereby authorize the physicians or designated staff to provide the necessary treatment to me. I also authorize the release of any medical information necessary to process claims and verify coverage. I understand that I am responsible for any deductibles, copays, and coinsurance not covered by my insurance policy. I acknowledge that I have read and understand the office and financial policies." Please Sign in the Box Below. *

Clear

Today's Date *

*If you are having trouble clicking the Submit Button you may have missed a field above, please make sure that you've filled everything out in full 😊