Intake Form Step 1 of 7 - Patient Info14%Please complete the NEW Patient Medical Intake Form below.*If you have not yet scheduled an appointment please call us at (732) 345-1377 or use Our Online Scheduler to Make an Appointment.**If you have an open Personal Injury case please DO NOT fill out this form - see front desk staff for injury-specific paperwork*You can also download and print/email the form here: Download Intake FormName* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth* Date Format: MM slash DD slash YYYY Age*Sex*Please SelectMaleFemaleSocial Security* Email* Best Contact Number*Contact Type*Please SelectCellHomeWorkEmergency Contact Name*Emergency Contact Phone*Your Occupation*How did you hear about us?*(Newspaper, Online, Patient Referral - Please be as specific as possible) Do you have insurance?*Please SelectYesNoIs your pain associated with an automobile or work related accident?*Please SelectYesNoIf yes, what was the date of the accident? Date Format: MM slash DD slash YYYY Do you have a Primary Care Physician?*Please SelectYesNoPrimary Care PhysicianPrimary Care Town List your chief complaints in order of severity:1When did it start?Please SelectGradualSuddenSeverityPlease SelectMildModerateSevere2When did it start?Please SelectGradualSuddenSeverityPlease SelectMildModerateSevere3When did it start?Please SelectGradualSuddenSeverityPlease SelectMildModerateSevereHeight*Weight*Have you had treatment for this condition?Please SelectYesNoWhen and Where did you receive treatment?Was treatment(s) successful?Please SelectYesNoIf NO, why? How often does the pain occur?Please SelectConstantEpisodicOccasionalWhat type of Pain?Please SelectSharpDullAchingShootingIs your condition getting worse?Please SelectYesNoWhat makes it feel better?What makes it feel worse?Please list activities of daily living which you've had difficulty doingEg. Job, relationship, recreational activities, household chores.Does your pain travel?Please SelectYesNoPlease indicate whereDo you have any numbness or tingling in the arms and/or hands?Please SelectYesNoFor how long?Do you have any weakness in the arms and/or hands?Please SelectYesNoFor how long?Do you have any numbness or tingling in the legs and or feet?Please SelectYesNoFor how long?Do you have any weakness in the legs and/or feet?Please SelectYesNoFor how long?Do you currently have, or have you had problems with the following? Anxiety Arthritis Bladder Cancer Chest Circulation Problems Depression Diabetes Type I Diabetes Type II Dizziness Ears Eyes Gi / Digestion Headaches Heart High Blood Pressure Insomnia Jaw Pain Kidneys Loss of Balance Lungs / Breathing Nausea/Vomiting Nose Osteoporosis Rheumatoid Arthritis Seizures Stomach / GI Ulcers Stroke Throat Thyroid VertigoPlease select all that apply.Do you have any other conditions or problems we should be aware of?Are you Pregnant?Please SelectNoYesDo you have a pacemaker?Please SelectNoYes List your hospitalizations, operations and/or serious illness:List all medications you are currently taking, prescribed and over - the - counter:List any allergies:Social habitTobaccoPlease SelectYesNoHow OftenAlcoholPlease SelectYesNoHow Often HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996This notice is in effect as of April 15, 2003.PATIENT’S STATEMENT OF AUTHORIZATION AND ACKNOWLEDGEMENTMonmouth Pain and Rehabilitation:a) Is required by federal law to maintain the privacy of your protected health information (PHI), and to provide you with a copy of this Privacy Notice detailing Monmouth Pain & Rehabilitation, P.C. legal duties and privacy practices with respect to your PHI.b) May be required by State law to maintain greater restrictions on the use or release of your PHI than that which is provided under federal law. Monmouth Pain & Rehabilitation, P.C. is required to, and will comply with all required State statutes.c) Is required to abide by the terms of this privacy notice.d) Reserves the right to change the terms of this privacy notice to make the new privacy notice provisions effective for your entire PHI that it maintains.e) Will distribute any revised Privacy Notice to you prior to implementation.f) Will comply with our complaint policy, and will not retaliate against you for filing a complaint.By subscribing my name below, I acknowledge that I have read and understood this Privacy Notice.Furthermore, I give Monmouth Pain & Rehabilitation, P.C. the expressed written consent to display my name in any “In-Office” usages, including but not limited to sign -in sheet, files, charts, mobile devices, and e-mail. I also understand that if my name is requested to be used for promotional purposes outside of the office, a separate acknowledgement of permission will made in writing.Accept Terms*Please type your name in acknowledgment of the above terms.Date* Date Format: MM slash DD slash YYYY Please select today's date in acknowledgment of the above terms.EmailThis field is for validation purposes and should be left unchanged.