DR. BARRY L. MARKS, DC
ORANGE SPINE & DISC REHABILITATION CENTER
2401 W. CHAPMAN AVE SUITE 102
ORANGE, CALIFORNIA 92868
(714) 938-0575
New Patient Application & Health Questionnaire

Please complete this application and questionnaire to determine whether we can accept your case and what your needs are.

Follow the directions and answer each question. Upon completion, select "submit" and your answers will be
transmitted for analysis.

Completing this questionnaire online will reduce your time waiting and filling out paperwork in the office.

Be sure to call our office at (714) 938-0575 to set an appointment to go over the results with Dr Marks.

...ooOoo...
Your Personal Demographic Info

Full Name
Street Address
City, State Zip
Email
Hm Telephone
Wk Telephone
Birthdate
Age
Last 4 # SSN
Marital status

   Minor Single Married Separated Divorced Widow
Spouse name
Children?

Yes No  How many?

 

Referred by

  
 

Employer

  
Occupation
How long?
Emply address
City, State, Zip
 

Emerg Contact

  
Telephone

 

...ooOoo...
Insurance Information
(Please list your primary health insurance information)

Insurance Co Name
Address
City, State, Zip
Telephone
Insured's ID#
Group #
Insured Name
Relation
Birthdate
Insured employer
 

Name of 2nd insurance

  
 

Uninsured

  

I am uninsured and will pay by cash, check or credit card

Notice to Medicare Patients

 
We are not Medicare Participating Providers. Medicare will NOT pay for any services in our office. However, your secondary insurance may cover your treatment.

The insurance info above is my secondary

 

...ooOoo...
My Reasons For Completing the Questionnaire
(Please explain why you are consulting with Dr Marks; Auto Accident, Sports,
Household, Gardening, Chronic problem, etc)

Briefly explain what happened?
 Briefly, what hurts?
   
Is your condition getting worse?
Yes No Comes and goes		 Condition interferes with:
Similar problem in past?
Yes No

Past chiropractic treatment?
 Yes No

 Explain prior treatment this condition

 

...ooOoo...
Health Questionnaire
(Check all that apply)

Check if you have or had:

Heart Attack/stroke
Heart defect
Heart surgery/Pacemaker
Blood pressure problems
Alcohol/Drug abuse
Psychiatric problems
HIV/AIDS
Hepatitis
Tuberculosis
Diabetes
Seizures
Cancer
Anemia
Asthma
Emphysema
Colitis
Unexplained weight loss
Night fevers
Menopause
PMS
Sinus problems
Artificial joints
Heartburn/Reflux
Frequent headaches
Frequent neck pain
Frequent middle back pain
Frequent low back pain
Sciatica
Foot/Heel pain
 		 Current medications

List any serious medical problems

List any allergies

List any surgeries

Past accidents with dates

Relevant Family Illnesses

Take diet supplements
Exercise regularly
Special diet
Smoke cigarettes
Drink alcohol
Consume caffeine regularly		 Wear orthotics or heel lifts
Take birth control pills
Pregnant
Nursing
Under stress
Comfortable bed

 

...ooOoo...
My Concerns
(Please briefly list, in order of importance, your top 3 concerns regarding your health)

1

2

3

 

...ooOoo...
My Current State of Health Satisfaction
(Indicate the degree of your satisfaction with various aspects of your life and health)
Scale = 0 Extremely Unsatisfied, 1 Minimally Satisfied, 2 Mildly Satisfied,
3 Moderately Satisfied, 4 Satisfied, 5 Very Satisfied

  0 1 2 3 4 5
Pain
Weight
Strength
Stamina
Energy
Emotions
Spirituality
Diet
Exercise
Relationships
Career

 

...ooOoo...
Pain Locator
(Use the numbered diagram to locate your pain. Check all that apply)

My pain is located...

I do not have any pain

    1    
2     3
4 5 6
7     8
9     10
11     12
13 14 15
16 17 18
19     20
21     22
23     24
25     26
27     28
29     30
31     32
33 34 35
    36    
37     38
39 40
41     42
43     44
45     46
47     48
49     50

 

 

 

 

 

Comments:

Pain Descriptor
(Use numbered diagram to describe the quality of your pain. Use commas between numbers)

Example: Ache at location(s): [4,5,6]
Burning at location(s): [10,12,14]

My Pain feels like...

Dull/aching @ location:
Burning @ location:
Electric @ location:
Pins & Needles @ location:
Sharp/Stabbing @ location:
Other @ location:
Other @ location:

Frequency Rater
(Select the best answer for how often you feel your pain)

My Pain Occurs...

Severity Rater
(Indicate how bad or severe your pain is below)

 My Pain is...

Minimal and is easily forgotten
Mild and I feel it during activity but it does not interfere with any activities
Slight and interferes only with strenuous activities
Slight to moderate and interferes with light activities and prevents strenuous activities
Moderate and prevents light activities
Severe and prevents all activities

Pain Aggravators
(Check all the conditions below that aggravate or make your pain worse)

My pain is aggravated by...

Sitting
Standing
Walking
Lying Down
Bending Forward
Bending Backward
Coughing and/or Sneezing
Lovemaking
Driving
Other:

Failed Treatments
(Despite trying the following treatments, I continue to suffer with back and/or leg pain)

Acupuncture Chiropractic
Home Exercises Physical therapy
Over the Counter Medications Prescription Medications
Nerve blocks Epidural steroid injection
Minimally Invasive Disc Surgery Disc Herniation Surgery
Laminectomy Surgery Fusion Surgery

 

You are finished! Click "submit" below to transmit your answers

Thank You For Completing the Questionnaire. If you have not done so already, call our office at (714) 938-0575 to set a convenient appointment time to go over the results with Dr. Marks

You may also print out this page and bring it with you on your appointment.

DR. BARRY L. MARKS, DC
ORANGE SPINE & DISC REHABILITATION CENTER
2401 W. CHAPMAN AVE SUITE 102
ORANGE, CALIFORNIA 92868
(714) 938-0575
http://www.drmarks.com
 

(C) Copyright 2008-2010 DR BARRY L MARKS, DC