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Call: 1 (775) 689-5410
Home
Our Team
Services
About
Conditions Treated
Treatments Options
Physical Therapy
Diagnostic Tools
Referring Physicians
Patients
New Patients
Patient Resources
Insurance Information
Forms
Contact
Patient Portal
NPSS Initial Intake Form
Comprehensive. Committed. Compassionate.
Step
1
of
11
0%
NPSS INITIAL INTAKE FORM
Name
First
Last
Today's Date:
MM slash DD slash YYYY
Date of Birth:
MM slash DD slash YYYY
Home Phone:
Mobile:
Patient Email ID
Emer Contact Cell Phone:
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
History of Present Illness
Duration
1 day
2 days
3 days
4 days
5 days
6 days
1 week
2 weeks
3 weeks
1 month
2 months
3 months
4 months
5 months
6 months
7 months
8 months
9 months
10 months
11 months
1 year
2 years
3 years
4 years
5 years
8 years
10 years
More than 10 Years
Onset
Sudden onset
Gradually over time
While bending
While climbing
While driving
When fell down
While getting down the stairs
While jumping
While lifting weight
When met with motor accident
While playing
While running
While standing up after prolonged standing
While walking
Frequency of pain
Constant
Intermittent
Infrequent
Rare
Seldom
Quality
Aching
Cramping
Dull
Hot-burning
Numbing
Pins and needle
Pressure like
Sharp
Shooting
Stabbing
Throbbing
Tingling
Radiation
Bilaterally into the head
Back
Bilateral lower extremity
Flank
Radiation
Left
Head
Shoulder
Upper arm
Forearm
Hand
Fingers
Upper extremity
Lower extremity
Hip
Thigh
Knee
Leg
Foot
Ankle
Radiation
Right
Head
Shoulder
Upper arm
Forearm
Hand
Fingers
Upper extremity
Lower extremity
Hip
Thigh
Knee
Leg
Foot
Ankle
Severity of pain at its worst
0/10
1/10
2/10
3/10
4/10
5/10
6/10
7/10
8/10
9/10
10/10
Severity of pain at its best
0/10
1/10
2/10
3/10
4/10
5/10
6/10
7/10
8/10
9/10
10/10
Severity of average pain
0/10
1/10
2/10
3/10
4/10
5/10
6/10
7/10
8/10
9/10
10/10
Severity of pain right now
0/10
1/10
2/10
3/10
4/10
5/10
6/10
7/10
8/10
9/10
10/10
Worsening factors
Bending
Changing position
Coughing
Defecation
Going up stairs
Going down stairs
Heat
Increased activity
Lying flat
Lifting
Movement
Sitting a long time
Sneezing
Standing a long time
Standing straight up
Turning to the left
Turning to the right
Turning side to side
Walking
Relieving factors
Assistive devices
Changing position
Cold
Exercise
Heat
Injections
Lying flat
Massage
Manipulation
Medications
Physical therapy
Rest
Sitting
Standing
Walking
Associated symptoms
Difficulty staying asleep due to pain
Feeling blue all the time
Frustrated because of pain
Increased pain with coughing and sneezing
Involuntary loss of bowel and bladder control
Muscle cramps
Need for sleeping pills
Non-restful sleep
Numbness
Recent fevers, chills or sweats
Restful sleep
Restrictions on the activities
Tingling
Unable to fall asleep
Unable to stay asleep
History of vertigo / dizziness
No
Yes
History of falls
No
Yes
History of fibromyalgia
No
Yes
Use of supporting devices
No
Yes
Comments
Treatment History
Caregivers you have visited
Pain medicine physician
Family physician
Spine surgeon
Internist
Physical therapist
General practitioner
Neurologist
Rheumatologist
Chiropractor
Orthopedist
General surgeon
Gynecologist
Sports medicine
Anesthesiologist
Occupational medicine
Rehabilitation medicine
Osteopathic physician
Acupuncturist
Podiatrist
Nurse practitioners
Psychiatrist
Urologist
Endocrinologist
Neurosurgeons
Tests undergone in the past
X-Rays
CAT Scan
EMG Test
Discogram
Neural Block
Myelogram
CT myelogram
Flexion/extension films
Bone scan
Nerve conduction studies
EEG
CBC
PT PTT INR
Rheumatologic panel
Neuropathy panel
Electrolytes
Lumbar puncture
EKG
Chest x-ray
Hepatic profile
MRI Scan
Medicines taken in the past
Alpha 2 agonist
Antidepressant
Anti-inflammatory meds
Baclofen
Beta-blockers
Calcium channel blockers
Codeine
Darvocet
Darvon
Depakote/depakoteER
Desipramine
Elavil/amitriptyline
Fentanyl/actiq
Flexeril/cyclobenzaprine
Gabitril
Hydrocodone
Hydromorphone
Keppra
Lyrica
Methadone
M. S. Contin
Muscle relaxant
Narcotics
Neurontin/gabapentin
Norflex
Opana
Oxycodone/oxycontin
Pamelor/nortriptyline
Paxil
Percocet
Protriptyline
Robaxin
Skelaxin
Soma
Tegretol
Topamax/topiramate
Ultram/ultram ER
Zonegran/zonisamide
Zanaflex/tizanidine
Treatment undergone in the past
Bed rest
Biofeedback
Celiac plexus block
Chemical denervation
Cryo- denervation
Discography
Epidural blood patch
Epidural steroid injection
Exercises
Facet injection
Ganglion impar block
Heat
Ice Injection therapy
Intercostal field block
Intrathecal infusion pump
IDET
Lumbar sympathetic block
Manipulation
Massage
Nerve block
Occipital nerve block
Physical therapy
Piriformis injection
Psychiatric treatment
Radiofrequency denervation
Sacroiliac joint injection
Stellate ganglion block
Superior hypogastric block
Surgery
TENS
Therapeutic injection
Traction
Trigger point injection
Vertebroplasty
Prior treatments of any help?
No
Yes
When was the prior tx started?
After couple of days after the onset
When the home remedies and other OTCs did not work
Immediately after the pain started
Immediately after the injury
After a few months wait
Comments
Allergy
No Known Allergy
No Known Allergy
Allergy
Sr. No
Allergy
Reaction
Add
Remove
Current Medication
No Known Current Medication
No Known Current Medication
Current Medication
Sr. No
Drug Name
Drug Name
Add
Remove
Past Medical History
No Known Past Medical History
No Known Past Medical History
Past Medical History
Sr. No
Ailment
Since When
Comments
Add
Remove
Past Surgical History
No Known Past Surgical History
No Known Past Surgical History
Past Surgical History
Sr. No
Surgery Name
When
Doctor
Hospital
Add
Remove
Family History
Non-Contributory Family History
Non-Contributory Family History
Family History
Sr. No
Problem
Relation
Comments
Add
Remove
Family
Marital Status
Marital Status
Single
Married
Divorced
Number of children
Nature of exercise
Pets
Sexual history
Use of Drugs/Alcohol/Tobacco
Are you concerned about the amount you drink?
Do you drink alcohol?
Do you drink alcohol?
Yes
No
If yes, what kind?
Smoking status
Smoking status
Yes
No
Caffeine intake
Caffeine intake
Yes
No
Do you currently use recreational or street drugs?
Do you currently use recreational or street drugs?
Yes
No
Used yourself street drugs with a needle?
No
Yes
Work History
Employment type
Placeholder
Placeholder
Nature of work
Placeholder
Placeholder
Occupational exposure
Placeholder
Placeholder
Exposure to health hazards
Health hazards at home
No
Yes
Duration of current profession
Satisfaction with the work
Placeholder
Placeholder
Stress level at work
Placeholder
Placeholder
REVIEW OF SYSTEMS
Constitutional Symptoms
Fever
Denies
Reports
Fatigue
Denies
Reports
Chills
Denies
Reports
Hot Flashes
Denies
Reports
Night Sweats
Denies
Reports
Weight Loss
Denies
Reports
Appetite
Placeholder
Placeholder
Physical Strength
Placeholder
Placeholder
HEENT
Headache
Denies
Reports
Dizziness
Denies
Reports
Double Vision
Denies
Reports
Loss of Vision
Denies
Reports
Corrective Lenses/Contacts
Denies
Reports
Pain in Eyes
Denies
Reports
Earaches
Denies
Reports
Discharge from Ears
Denies
Reports
Deafness/Hearing Loss
Denies
Reports
Frequent Nose Bleeds
Denies
Reports
Sinus Problems
Denies
Reports
Smelling Sense Change
Denies
Reports
Sore Throat
Denies
Reports
Swallowing Difficulty
Denies
Reports
Taste Difficulty
Denies
Reports
Hoarseness
Denies
Reports
Respiratory
Trouble breathing
Denies
Reports
Shortness of Breath
Denies
Reports
Asthma
Denies
Reports
COPD/Emphysema
Denies
Reports
Sputum Production
Denies
Reports
Coughing up Blood
Denies
Reports
Sleep Apnea
Denies
Reports
Orthopnea
Denies
Reports
Wheezing
Denies
Reports
Respiratory Infections
Denies
Reports
Cardiovascular
Chest Pain
Denies
Reports
Poor Circulation
Denies
Reports
Blood Clots
Denies
Reports
Irregular Heart Beat
Denies
Reports
Thumping in the Chest
Denies
Reports
Limb Swelling
Denies
Reports
Limb Pain on Walking
Denies
Reports
Ankle Swelling
Denies
Reports
Feet Swelling
Denies
Reports
Varicose Veins
Denies
Reports
PND
Denies
Reports
Phlebitis
Denies
Reports
Gastrointestinal
Abdominal Pain
Denies
Reports
Indigestion
Denies
Reports
Gastroesophageal Reflux Disorder
Denies
Reports
Heart Burn
Denies
Reports
Nausea or Vomiting
Denies
Reports
Vomiting of Blood
Denies
Reports
Frequent Constipation
Denies
Reports
Frequent Diarrhea
Denies
Reports
Stomach Ulcer
Denies
Reports
Painful bowel Movement
Denies
Reports
Chronic Bloating
Denies
Reports
Blood in Stool
Denies
Reports
Hemorrhoids/Piles
Denies
Reports
Jaundice
Denies
Reports
Genitourinary
Untitled
First Choice
Second Choice
Third Choice
Incontinence
Denies
Reports
Blood in Urine
Denies
Reports
Kidney Stones
Denies
Reports
Difficulty in Urination
Denies
Reports
Musculoskeletal
Muscle Pain
Denies
Reports
Muscle Cramp
Denies
Reports
Muscle Twitches
Denies
Reports
Muscle Wasting
Denies
Reports
Muscle Weakness
Denies
Reports
Muscle Pain or Tenderness
Denies
Reports
Loss of Muscle bulk
Denies
Reports
Neck Pain
Denies
Reports
Shoulder Pain
Denies
Reports
Back Pain
Denies
Reports
Joint Pain
Denies
Reports
Joint Stiffness
Denies
Reports
Joint Swelling
Denies
Reports
Morning Stiffness
Denies
Reports
Abnormal Joints
Denies
Reports
Limitation of Joint Movement
Denies
Reports
Fractures
Denies
Reports
Arthritis
Denies
Reports
Swollen Joints
Denies
Reports
Night Cramps
Denies
Reports
Atrophy
Denies
Reports
Posture Abnormalities
Denies
Reports
Neurological
Seizures
Denies
Reports
Blackouts
Denies
Reports
Trouble with Memory
Denies
Reports
Trouble Concentrating
Denies
Reports
Gait Disturbance
Denies
Reports
Headache
Denies
Reports
Stroke
Denies
Reports
Loss of Strength
Denies
Reports
Fainting Spells
Denies
Reports
Memory Loss
Denies
Reports
Involuntary Movements
Denies
Reports
Poor Coordination
Denies
Reports
Numbness
Denies
Reports
Spasticity
Denies
Reports
Weakness
Denies
Reports
Tremors
Denies
Reports
Psychiatric
Anxiety
Denies
Reports
Depression
Denies
Reports
Mood Swings
Denies
Reports
Nervousness
Denies
Reports
Sleeping Difficulty
Denies
Reports
Endocrine
Excessive Thirst
Denies
Reports
Heat or Cold Intolerance
Denies
Reports
Excessive Urination
Denies
Reports
Thyroid Problem
Denies
Reports
Polyuria
Denies
Reports
Diabetes
Yes
No
Hematologic
Bleeding Disorder
Denies
Reports
Anemia
Denies
Reports
Easy Bruising
Denies
Reports
Blood Transfusions
Denies
Reports
Thank you very much for taking the time to complete this form.
NPSS Questionnaire 1
How often you been bothered by the following over the past 2 weeks?
Little interest or pleasure in doing things
(Required)
Not at all
Several days
More than half the days
Nearly every day
Feeling down, depressed or hopeless
(Required)
Not at all
Several days
More than half the days
Nearly every day
Trouble falling asleep, staying asleep
(Required)
Not at all
Several days
More than half the days
Nearly every day
Feeling tired or having little energy
(Required)
Not at all
Several days
More than half the days
Nearly every day
Poor appetite or overeating
(Required)
Not at all
Several days
More than half the days
Nearly every day
Feeling bad about yourself
(Required)
Not at all
Several days
More than half the days
Nearly every day
Trouble concentrating on things
(Required)
Not at all
Several days
More than half the days
Nearly every day
Moving or speaking so slowly
(Required)
Not at all
Several days
More than half the days
Nearly every day
Thoughts of death or hurting yourself
(Required)
Not at all
Several days
More than half the days
Nearly every day
How often have you been bothered by the following over the past 2 weeks?
Feeling nervous, anxious, or on edge
(Required)
Not at all
Several days
More than half the days
Nearly every day
Not being able to stop or control worrying
(Required)
Not at all
Several days
More than half the days
Nearly every day
Worrying too much about different things
(Required)
Not at all
Several days
More than half the days
Nearly every day
Trouble relaxing
(Required)
Not at all
Several days
More than half the days
Nearly every day
Being so restless that its hard to sit still
(Required)
Not at all
Several days
More than half the days
Nearly every day
Becoming easily annoyed or irritable
(Required)
Not at all
Several days
More than half the days
Nearly every day
Feeling afraid as if something awful might happen
(Required)
Not at all
Several days
More than half the days
Nearly every day
Over the past 30 days, how much difficulty have you had doing the following activities?
In the last 30 days, how much difficulty did you have in Concentrating on doing something for ten minutes?
(Required)
None
Mild
Moderate
Severe
Extreme or Cannot do
In the last 30 days, how much difficulty did you have in Remembering to do important things?
(Required)
None
Mild
Moderate
Severe
Extreme or Cannot do
In the last 30 days, how much difficulty did you have in Analyzing and finding solutions to problems in day-to-day life?
(Required)
None
Mild
Moderate
Severe
Extreme or Cannot do
In the last 30 days, how much difficulty did you have in learning a new task, for example, learning how to get to a new place?
(Required)
None
Mild
Moderate
Severe
Extreme or Cannot do
In the last 30 days, how much difficulty did you have in Generally understanding what people say?
(Required)
None
Mild
Moderate
Severe
Extreme or Cannot do
In the last 30 days, how much difficulty did you have in Starting and maintaining a conversation ?
(Required)
None
Mild
Moderate
Severe
Extreme or Cannot do
In the last 30 days, how much difficulty did you have in Standing for long periods such as 30 minutes?
(Required)
None
Mild
Moderate
Severe
Extreme or Cannot do
In the last 30 days, how much difficulty did you have in Standing up from sitting down?
(Required)
None
Mild
Moderate
Severe
Extreme or Cannot do
In the last 30 days, how much difficulty did you have in Moving around inside your home?
(Required)
None
Mild
Moderate
Severe
Extreme or Cannot do
In the last 30 days, how much difficulty did you have in Getting out of your home?
(Required)
None
Mild
Moderate
Severe
Extreme or Cannot do
In the last 30 days, how much difficulty did you have in Walking a long distance such as a kilometer (or equivalent)?
(Required)
None
Mild
Moderate
Severe
Extreme or Cannot do
In the last 30 days, how much difficulty did you have in Washing your whole body?
(Required)
None
Mild
Moderate
Severe
Extreme or Cannot do
In the last 30 days, how much difficulty did you have in Getting dressed?
(Required)
None
Mild
Moderate
Severe
Extreme or Cannot do
In the last 30 days, how much difficulty did you have in Eating?
(Required)
None
Mild
Moderate
Severe
Extreme or Cannot do
In the last 30 days, how much difficulty did you have in Staying by yourself for a few days?
(Required)
None
Mild
Moderate
Severe
Extreme or Cannot do
In the last 30 days, how much difficulty did you have in Dealing with people you do not know?
(Required)
None
Mild
Moderate
Severe
Extreme or Cannot do
In the last 30 days, how much difficulty did you have in Maintaining a friendship?
(Required)
None
Mild
Moderate
Severe
Extreme or Cannot do
In the last 30 days, how much difficulty did you have in Getting along with people who are close to you?
(Required)
None
Mild
Moderate
Severe
Extreme or Cannot do
In the last 30 days, how much difficulty did you have in Making new friends?
(Required)
None
Mild
Moderate
Severe
Extreme or Cannot do
In the last 30 days, how much difficulty did you have in Sexual activities?
(Required)
None
Mild
Moderate
Severe
Extreme or Cannot do
In the last 30 days, how much difficulty did you have in Taking care of your household responsibilities?
(Required)
None
Mild
Moderate
Severe
Extreme or Cannot do
In the last 30 days, how much difficulty did you have in Doing most important household tasks well?
(Required)
None
Mild
Moderate
Severe
Extreme or Cannot do
In the last 30 days, how much difficulty did you have in Getting all the household work done that you needed to do?
(Required)
None
Mild
Moderate
Severe
Extreme or Cannot do
In the last 30 days, how much difficulty did you have in Getting your household work done as quickly as needed?
(Required)
None
Mild
Moderate
Severe
Extreme or Cannot do
In the last 30 days, how much difficulty did you have in Your day-to-day work/school?
(Required)
None
Mild
Moderate
Severe
Extreme or Cannot do
In the last 30 days, how much difficulty did you have in Doing your most important work/school tasks well?
(Required)
None
Mild
Moderate
Severe
Extreme or Cannot do
In the last 30 days, how much difficulty did you have in Getting all the work done that you need to do?
(Required)
None
Mild
Moderate
Severe
Extreme or Cannot do
In the last 30 days, how much difficulty did you have in Getting your work done as quickly as needed?
(Required)
None
Mild
Moderate
Severe
Extreme or Cannot do
In the last 30 days, how much difficulty did you have in How much of a problem did you have in joining in community activities (for example, festivities, religious or other activities) in the same way as anyone else can?
(Required)
None
Mild
Moderate
Severe
Extreme or Cannot do
In the last 30 days, how much difficulty did you have in How much of a problem did you have because of barriers or hindrances inthe world around you?
(Required)
None
Mild
Moderate
Severe
Extreme or Cannot do
In the last 30 days, how much difficulty did you have in How much of a problem did you have living with dignity because of the attitudes and actions of others?
(Required)
None
Mild
Moderate
Severe
Extreme or Cannot do
In the last 30 days, how much difficulty did you have in How much time did you spend on your health condition, or its consequences?
(Required)
None
Mild
Moderate
Severe
Extreme or Cannot do
In the last 30 days, how much difficulty did you have in How much have you been emotionally affected by your health condition?
(Required)
None
Mild
Moderate
Severe
Extreme or Cannot do
In the last 30 days, how much difficulty did you have in How much has your health been a drain on the financial resources of you or your family?
(Required)
None
Mild
Moderate
Severe
Extreme or Cannot do
In the last 30 days, how much difficulty did you have in How much of a problem did your family have because of your health problems?
(Required)
None
Mild
Moderate
Severe
Extreme or Cannot do
In the last 30 days, how much difficulty did you have in How much of a problem did you have in doing things by yourself for relaxation or pleasure?
(Required)
None
Mild
Moderate
Severe
Extreme or Cannot do
NPSS Questionnaire 2
Name
First
Last
Date of Birth
MM slash DD slash YYYY
Gender
Male
Female
1. Family History of Substance Abuse
Alcohol
No
Yes
Illegal Drugs
No
Yes
Prescription Drug
No
Yes
2. Personal History of Substance Abuse
Alcohol
No
Yes
Illegal Drugs
No
Yes
Prescription Drug
No
Yes
3. Age (if 16-45)
Alcohol
No
Yes
Illegal Drugs
No
Yes
Prescription Drug
No
Yes
History of Preadolescent Sexual Abuse
History of Preadolescent Sexual Abuse
No
Yes
5. Psychological Disease
Attention Deficit Disorder <br>Obsessive Compulsive Disorder <br>Bipolar <br>Schizophrenia
No
Yes
Depression
No
Yes
NPSS Questionnaire 3
Name
First
Last
DOB
MM slash DD slash YYYY
DOS
MM slash DD slash YYYY
Instructions: Select Yes/No for appropriate answer
Have you ever felt that you ought to cut down on your drinking or drug use?
Yes
No
Have people annoyed you by criticizing your drinking or drug use?
Yes
No
Have you ever felt bad or guilty about your drinking or drug use?
Yes
No
Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?
Yes
No
Email
This field is for validation purposes and should be left unchanged.
