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Fill Out a New Patient Application

You are in a secure area. Please fill out the New Patient Registration Form before you come for your consultation. Once completed, click on submit and we will have your information when you come in.

Reason for your visit (check all that apply):

Neck Pain
Back Pain
Extremity pain, tingling or numbness
Brain Injury
Headaches
Laser Spine Surgery Consult
Surgical Consult
Surgical 2nd Opinion
Pain Management
Auto Accident
Work Accident
Need MRI

Name *

First

Last

Date of Birth

Marital Status

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Employment

Occupation

Employer

Employer Address

Health Insurance Information

Primary Insurance

Insurance ID#

Group#

Secondary Insurance

Secondary Insurance ID#

Secondary Insurance Group#

Primary Care Name

Primary Care Phone

Chiropractor Name

Chiropractor Phone

Pharmacy

Pharmacy Address

Accident Related Questions

Is this related to:

Auto Accident
Work Accident
Fall or Other
Not Related to an Accident

Auto Insurance Address

Address Line 1

Address Line 2

City

State

Zip Code

Your auto insurance name

Auto Insurance Phone

Adjuster name, if work related

Have you seen any other doctors for this injury?

Chiropractor
Physical Therapist
Orthopedics
Family doctor
Other

Imaging Tests Done

X-Ray(s)
MRI(s)
CT Scan(s)
Other

Date of Injury or Accident

Please state the reason you are here today

Please list past surgeries

Please list all medications you are currently taking

Please list all allergies to drugs or food

Do you presently use or have used illicit drugs such as cocaine?

Do you drink alcohol?

Do you smoke?

How often?

Family Medical History

Mother History

Diabetes
Cancer
Heart Disease
Hypertension
Stroke
Deceased
N/A

Father History

Diabetes
Cancer
Heart Disease
Hypertension
Stroke
Deceased
N/A

Brother(s)

Diabetes
Cancer
Heart Disease
Hypertension
Stroke
Deceased
N/A

Sister(s)

Diabetes
Cancer
Heart Disease
Hypertension
Stroke
Deceased
N/A

Personal Medical History

Please check all that apply to you

Palpitations
Chest Pain
Weight Loss
Weight Gain
Muscle Cramps
Back Pain
Neck Pain
Headaches
Anxiety
Syncope or Fainting
Feet Swelling
Joint Swelling
Joint Stiffness
Feeling Hot
Feeling Cold
Hearing Problems
Vision Problems
Cough
Shortness of Breath
Diarrhea
Constipation
Urinary Symptoms

Medical Conditions

Diabetes
Cancer
Heart Disease
Hypertension
Stroke
Kidney Disease
N/A

Other medical information you would like us to know?

Neck or Arm Pain

Do you have neck or arm pain?

Yes
No

My neck pain is

Constant
Frequent
Comes and Goes

My arm has feelings of

Pain
Tingling
Numbness

Which arm do you experience these symptoms?

Right
Left
Both

Which side is worse?

Right
Left

How long have you had arm pain?

Less than 6 weeks
More than 6 weeks

Which pain is worse?

Neck pain is worse than leg pain
They are equal
Arm pain is worse than back pain

What makes your neck pain worse?

What makes your neck pain better?

What makes your arm pain worse?

What makes your arm pain better?

Please check all that apply

I have weakness in my right arm
I have weakness in my left arm
My handwriting is getting worse
My balance seems worse lately
I seem to drop things easily
I have difficulty buttoning my shirts
I have numbness in my hands
I have numbness in my arms

How much NECK pain are you experiencing on a scale from 0-10 with 0 being no pain & 10 being the worst?

Selected Value: 0

How much ARM pain are you experiencing on a scale from 0-10 with 0 being no pain & 10 being the worst?

Selected Value: 0

Back or Leg Pain

Do you have back or leg pain?

Yes
No

My back pain is

Constant
Frequent
Comes and goes

My back pain is

above my belt line
at my belt line
below my belt line

My leg pain is

Constant
Frequent
Comes and goes

The pain is in my

Right leg
Left leg

Which pain is worse?

Back pain is worse than leg pain
They are equal
Leg pain is worse than back pain

I have more pain in my

Right leg
Left leg

My back pain is worse with

Sitting
Standing
Lying down
Walking

What eases your back pain?

Sitting
Standing
Lying down
Walking

My leg pain is worse with

Sitting
Standing
Lying down
Walking

What eases your leg pain?

Sitting
Standing
Lying down
Walking

How much BACK pain are you experiencing on a scale from 0-10 with 0 being no pain & 10 being the worst?

Selected Value: 0

How much LEG pain are you experiencing on a scale of 0-10 with 0 being no pain & 10 being the worst pain?

Selected Value: 0

Treatments You've Tried

Check all that apply

Chiropractic
Physical Therapy
Primary Care
Injections
Pain Management
Traction
Surgery

Other

Do we have your permission to leave a message on the phone number(s) you have provided?

May we discuss your medical information with...(family, attorney, PCP, chiropractor)

If someone calls for you or comes in and asks for you while you are here, do we have permission to tell them you are here?

Whom may we discuss your medical records with (please list names)?

How did you hear about us?

Please specify

Consent *

By checking, I agree to share my form responses with Allspine Laser and Surgery Center.

Our Locations

AllSpine Surgery Center Lic#044-359 | Minimally Invasive Neuro Institute Lic#075-462

Stockbridge, GA Office
900 Eagles Landing Pkway
Stockbridge, GA 30281
Phone: 770-997-0600
Fax: 678-565-3625
OPEN MRI & Surgery Center

See Map

Newnan, GA Office
3229 Highway 34 East, Suite 103
Newnan, GA 30265
Phone: 770-997-0600
Fax: 678-565-3625

See Map

Decatur, GA Office
1944 Clairmont Rd
Decatur, GA 30033
Phone: 770-997-0600
Fax: 678-565-3625
OPEN MRI & Surgery Center

See Map

Marietta, GA Office
2470 Windy Hill Road, Ste. 260
Marietta, GA 30067
Phone: 770-997-0600
Fax: 678-565-3625

See Map

College Park, GA Office
1720 Phoenix Blvd, Ste 570
College Park, GA 30349
Phone: 770-997-0600
Fax: 678-565-3625

See Map

Call Us - 770-997-0600

Business Hours

Mon to Fri – 8:30 AM – 5:00 PM
Sat & Sun – Closed

Fill Out a New Patient Application

Health Insurance Information

Accident Related Questions

Family Medical History

Personal Medical History

Neck or Arm Pain

Back or Leg Pain

Treatments You've Tried

Business Hours

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