New Patient Information (*=Required Field)

First Name

Middle Name

Last Name

Preferred Name

Driver's License #/ID (Optional)

Date of Birth

Age

Gender?*
MaleFemale

Status?*
SingleMarriedSeparatedDivorcedWidowed

Your Phone Number

Address

City

State

Zip

Emergency Contact #1

Contact #1 Phone

Relationship of Emergency Contact #1
SpouseFamilyFriendOther

Emergency Contact #2

Contact #2 Phone

Relationship of Emergency Contact #2
SpouseFamilyFriendOther

Insurance Information

Do You Have Health Insurance?*
YesNo

If yes please bring insurance card to the office on your first visit.

Auto Insurance Information

Check All That You Have
Auto InsurancePersonal Injury Protection (PIP)Uninsured MotoristMed Pay

Auto Insurance Policy Provider

Auto Insurance Policy Number

Auto Insurance Phone Number

Adjuster's Name

Claim #

Third Party Liability (if applicable)

3rd Party Auto Insurance Policy Provider

3rd Party Auto Insurance Policy Number

3rd Party Auto Insurance Phone Number

3rd Party Adjuster's Name

If you do not have the information of the person at fault, please bring the third party liability information with you on your next visit. Thank you!

Review of Symptoms

Constitutional*
N/AFaintingLow LibidoPoor AppetiteFatigueSudden Weight GainSudden Weight LossWeakness

Respiratory*
N/AAsthmaApneaEmphysemaHay FeverShortness of BreathPneumonia

Cardiovascular*
N/AHigh Blood PressureLow Blood PressureHigh CholesterolPoor CirculationAnginaExcessive Bleeding

Gastrointestinal*
N/AAnorexia/BulimiaUlcerFood SensitivitiesHeartburnConstipationDiarrhea

Genitourinary*
N/AKidney StonesInfertilityBedwettingProstate IssuesErectile DysfunctionPMS Symptoms

Integumentary*
N/ASkin CancerPsoriasisEczemaAcneHair LossRash

Neurological*
N/ABlurred VisionRinging in EarsHearing LossChronic Ear InfectionLoss of SmellLoss of Taste

Endocrine*
N/AThyroid IssuesImmune DisordersHypoglycemiaFrequent InfectionSwollen GlandsLow Energy

Describe Any Other Medical Issues Not Listed

History

Mother's Family History

Mother's Age (or age at death)

State of Health*
GoodFairPoorN/A

Cause of Death*
NaturalIllnessOtherN/A-Still Living

History of these illnesses *
CancerStrokeHeart DiseaseDiabetesAuto-ImmuneN/A

Other Illness, what was it?

Father's Family History

Father's Age (or age at death)

State of Health*
GoodFairPoorN/A

Cause of Death*
NaturalIllnessOtherN/A-Still Living

History of these illnesses *
CancerStrokeHeart DiseaseDiabetesAuto-ImmuneN/A

Other Illness, what was it?

Social History

Alcohol Use

Coffee Use

Tobacco Use

Exercise

Pain Relievers

Soft Drinks

Water

Past Medical History

Illness*
N/AAIDSAlcoholismAllergiesArteriosclerosisCancerChicken PoxDiabetesEpilepsyGlaucomaGoiterGoutHeart diseaseHepatitisHIV PositiveMalariaMeaslesMultiple SclerosisMumpsScarlet feverSexually transmitted diseasePolioRheumatic feverStrokeTuberculosisTyphoid feverUlcer

Are there any other illnesses to mention?

Any surgeries PRIOR to injury?

Surgeries* N/AAppendix removalBypass surgeryCancer relatedCosmetic surgeryEye surgeryHysterectomyPacemakerTonsillectomySpinal SurgeryJoint Surgery

Elective Surgeries?

Other Surgeries?

Medications & Allergies

Please list below all prescription, over-the-counter or natural supplements you are taking

List Medication

Are you allergic to any medications?

Allergies*
YesNoNot Sure

If yes, please list

Dominant Hand

Dominant Hand*
RightLeftAmbidextrous (both)

ACCIDENT INFORMATION

Select The Type of Accident You Had

Type of Accident*
Auto AccidentSlip & Fall/Personal Injury

"PERSONAL INJURY or SLIP/FALL"

Report Filed*
YesNo

Describe How and Where the injury occurred:

Describe Accident

Address

City

County/State

MECHANISM OF INJURY*
FallSlipTripOther

Did You Fall:*
ForwardBackwardsLeftRightN/A

How Far Did You Fall?

Time of Day?

Did you fall off of something or into something?*
YesNo

Please Describe

What body parts were hit/impacted

Were you able to catch yourself?*
YesNoN/A

Please Describe how you were able to catch yourself

Did you hit your head?*
YesNo

Did you lose consciousness?*
YesNoNot Sure

Upload INJURY Pictures | Filetypes:jpeg|png|jpg File size limit:5242880 Bytes

"MOTOR VEHICLE ACCIDENT (Patient)"

Was A Police Report Filed*
Yes (Bring Copy)No

Motor Vehicle Information

Your Vehicle(s) was a:

Other Vehicle(s) was a

Direction of Impact:*
Rear-endedFront-end impactedT-Boned Driver SideT-Boned Passenger SideRolloverSide Impact Driver SideSide Impact Passenger SideOther

Location of Impact:*
FrontSideRearOther

How Many Cars Involved?

Weather Conditions*
DryRainIceFogOther

Time of day the accident occured*
MorningNoonAfternoonEveningOvernight

Did your car strike anything else after impact?

How far did your car move as a result of the impact?

MECHANISM OF INJURY

Patient Name

You Were The:*
DriverFront PassengerLeft-Rear PassengerMiddle-Rear PassengerRight-Rear PassengerOther

Were you wearing your seatbelt?*
YesNo

Did your airbag deploy?*
YesNo

Were you able to brace for impact?*
YesNo

Were you facing:*
Straight AheadLeftRightUnsure

Did any part of your body hit any part of the car?*
YesNoUnsure

If yes, describe below

Upload MOTOR VEHICLE ACCIDENT Pictures | Filetypes:jpeg|png|jpg File size limit:5242880 Bytes

Upload INJURY Pictures | Filetypes:jpeg|png|jpg File size limit:5242880 Bytes

Post-Injury Questionnaire

Did you go to the hospital following your accident?
YesNo

Did you use an Ambulance?*
YesNo

Name of Hospital (please provide us with your discharge paperwork)

When did you go to the Hospital?
Immediately AfterA few hours afterOne day laterA few days laterCan't Remember

What Tests or Diagnostics Were Done? (select all that apply)
MRICT ScanX-RaysTests conducted Lying DownTests Conducted Standing

Describe Tests Conducted

Were you treated at the scene of the accident?
YesNo

Have you seen any other healthcare providers for this injury?
YesNo

Name of Other Clinic or Doctor

SINCE THE ACCIDENT

Self-care has consisted of: (select all that apply)*
Prescription medicationOTC medicationHomeopathic remediesSurgeryAcupunctureChiropractic careIceHeatMassagePhysical TherapyRestPain Relief CreamsWearing a support/braceOtherNone

List any Other Self-Care here

ACTIVITIES OF DAILY LIVING

How injuries sustained currently interfere with life and ability to function: (select all that apply)*
SittingRising out of chairStandingWalkingLying downBending overClimbing stairsDriving a carTurning headHousehold choresLifting objectsReaching upShowering or bathingGetting dressedLove lifeSleepConcentratingExercisingOtherNone

List any Other Activities here

Work Status

Were you employed at the time of your accident?*
YesNo

List Occupation

Are you self-employed?*
YesNo

If not Employed, select any that apply
StudentRetiredDisabledHomemaker

Have you missed work because of this accident?
YesNo

If Yes, How Long?

Why have you missed work?
A doctor took you off workYou took yourself off workYou had no transportation after the accidentYour boss took you off workYou were fired or lost your job as a result of this accidentOther

List any other reason you missed work:

Do you continue to work despite the pain?*
YesNoN/A

Have you returned to work as of today?
YesNoN/A

Are you working restricted or light duty?
YesNoN/A

If Yes, list any work restrictions:

Communications Authorization

By checking this box you authorize Texas Healthcare Neck and Back P.A. to contact you via phone, email or text to provide you information about your upcoming appointments or to assist you with your healthcare forms.*

By providing a telephone number and submitting this form you are consenting to be contacted by SMS text message. Your personal information will not be shared with any third parties for marketing purposes. You may opt out of messaging anytime by replying STOP, CANCEL, or UNSUBSCRIBE to any message we send or contacting us at (972) 392-3400. For electronic communciations, messaging or data rates may apply. For further informaiton, please review our Privacy Policy.

Any information that is not provided while filling out this form will need to be reviewed at the clinic on your first visit. By providing this information at this time, your initial appointment intake process will not be so lengthy. Your doctor will need a health history to complete the initial exam.

Additional forms will need to be signed when you arrive at the clinic on your first visit.
Please bring a photo ID and any previous care information related to your accident if applicable.
Thank you!

I will remember to Bring a photo IDI will also bring any previous care information related to my accidentI understand that I will need to Sign any additional forms when I arrive for my first visit

New Patient Form-Single Page

This is a detailed Health Information Form that is designed to better help us understand your specific requirements. Please invest a few minutes now and save yourself from having to revisit this form with the intake assistant during your first appointment. Fields with a * are required.

New Patient Information (*=Required Field)

Insurance Information

If yes please bring insurance card to the office on your first visit.

Auto Insurance Information

If you do not have the information of the person at fault, please bring the third party liability information with you on your next visit. Thank you!

Review of Symptoms

History

Social History

Past Medical History

Any surgeries PRIOR to injury?

Medications & Allergies

Please list below all prescription, over-the-counter or natural supplements you are taking

Dominant Hand

ACCIDENT INFORMATION

Select The Type of Accident You Had

"PERSONAL INJURY or SLIP/FALL"

Describe How and Where the injury occurred:

Upload INJURY Pictures | Filetypes:jpeg|png|jpg File size limit:5242880 Bytes

"MOTOR VEHICLE ACCIDENT (Patient)"

Motor Vehicle Information

MECHANISM OF INJURY

Upload MOTOR VEHICLE ACCIDENT Pictures | Filetypes:jpeg|png|jpg File size limit:5242880 Bytes

Upload INJURY Pictures | Filetypes:jpeg|png|jpg File size limit:5242880 Bytes

Post-Injury Questionnaire

SINCE THE ACCIDENT

ACTIVITIES OF DAILY LIVING

Work Status

Communications Authorization

Additional forms will need to be signed when you arrive at the clinic on your first visit.
Please bring a photo ID and any previous care information related to your accident if applicable.
Thank you!

(972) 392-3400

New Patient Form-Single Page

This is a detailed Health Information Form that is designed to better help us understand your specific requirements. Please invest a few minutes now and save yourself from having to revisit this form with the intake assistant during your first appointment. Fields with a * are required.

New Patient Information (*=Required Field)

Insurance Information

If yes please bring insurance card to the office on your first visit.

Auto Insurance Information

If you do not have the information of the person at fault, please bring the third party liability information with you on your next visit. Thank you!

Review of Symptoms

History

Social History

Past Medical History

Any surgeries PRIOR to injury?

Medications & Allergies

Please list below all prescription, over-the-counter or natural supplements you are taking

Dominant Hand

ACCIDENT INFORMATION

Select The Type of Accident You Had

"PERSONAL INJURY or SLIP/FALL"

Describe How and Where the injury occurred:

Upload INJURY Pictures | Filetypes:jpeg|png|jpg File size limit:5242880 Bytes

"MOTOR VEHICLE ACCIDENT (Patient)"

Motor Vehicle Information

MECHANISM OF INJURY

Upload MOTOR VEHICLE ACCIDENT Pictures | Filetypes:jpeg|png|jpg File size limit:5242880 Bytes

Upload INJURY Pictures | Filetypes:jpeg|png|jpg File size limit:5242880 Bytes

Post-Injury Questionnaire

SINCE THE ACCIDENT

ACTIVITIES OF DAILY LIVING

Work Status

Communications Authorization

Additional forms will need to be signed when you arrive at the clinic on your first visit. Please bring a photo ID and any previous care information related to your accident if applicable. Thank you!

(972) 392-3400

Additional forms will need to be signed when you arrive at the clinic on your first visit.
Please bring a photo ID and any previous care information related to your accident if applicable.
Thank you!