Patient & Visitor Information

Request An Appointment

This form is for NON-URGENT APPOINTMENTS ONLY.

Please complete the information below. Once submitted, our office will contact you within one business day to schedule your appointment. If you have an emergency, call 911 immediately or go to your nearest emergency room. We do not respond to emergencies through this website.

If you’d like to download and print the form instead you can do so here:

New Patient Registration Packet | En Español

"*" indicates required fields

Name*

First Middle Last

Date of Birth:*

NO SHOW/LATE CANCELLATION APPOINTMENT POLICY*

I Have Read & Agree that: We, at Emed Multispecialty Group, understand that sometimes you need to cancel or reschedule your appointment and that there are emergencies. If you are unable to keep your appointment, please call us as soon as possible (with at least a 24-hour notice). For your convenience, there are several options available to cancel your appointment. (1) Call us at (904) 206-7132 during our normal business hours. (2) If you call after hours, our after-hour phone service is available to assist you. (3) Download the HEALOW app for access to cancel or make an appointment. To ensure that each patient is given the proper amount of time allotted for their visit and to provide the highest quality care, it is very important for each scheduled patient to attend their visit on time. As a courtesy, we will attempt to send an appointment reminder call/text at least (1) business day prior to your scheduled appointment. Please ensure we have your updated phone number on file. However, it is the responsibility of the patient to arrive for their appointment on time. PLEASE REVIEW THE FOLLOWING POLICY: • Please cancel your appointment with at least a 24 hours’ notice: There is a waiting list to see the Providers at Emed and whenever possible, we like to fill cancelled spaces to shorten the waiting period for our patients. • If less than a 24-hour cancellation is given this will be documented as a “No-Show” or “Late Cancellation” appointment and will be assessed a $20.00 no show or late cancellation fee. I have read and understand Emeds No Show/Late Cancellation Appointment Policy and understand my responsibility to plan appointments accordingly

Signature

What treatment are you seeking today?*

Pain Medication (Opiate Treatment)

Narcotic Addiction (Buprenorphine/Suboxone)

Anxiety Medication

ADD/ADHD Medication

Pain Management Questionnaire

How long have you had your current pain?*

Days

Weeks

Months

Years

Out of 10, what is your pain level today?*

Please choose the areas that hurt:*

please, only choose top 2 areas that hurt.

Information about your HEAD pain:

Have you ever had surgery on this area?*

Yes

No

Is this pain the result of a major trauma or accident?*

Yes

No

Does your pain prevent you from doing daily activities?*

Yes

No

How would you describe your pain?*

Does your pain radiate?*

Does anything make your pain worse?*

Does anything improve your pain?*

Is there tingling/numbness?*

Yes

No

Is there swelling in the area?*

Yes

No

Is the pain worse with movement?*

Yes

No

Are you currently taking medications for this?*

Yes

No

Information about your NECK pain:

Have you ever had surgery on this area?*

Yes

No

Is this pain the result of a major trauma or accident?*

Yes

No

Does your pain prevent you from doing daily activities?*

Yes

No

How would you describe your pain?*

Does your pain radiate?*

Does anything make your pain worse?*

Does anything improve your pain?*

Is there tingling/numbness?*

Yes

No

Is there swelling in the area?*

Yes

No

Is the pain worse with movement?*

Yes

No

Are you currently taking medications for this?*

Yes

No

Information about your MIDDLE BACK pain:

Have you ever had surgery on this area?*

Yes

No

Is this pain the result of a major trauma or accident?*

Yes

No

Does your pain prevent you from doing daily activities?*

Yes

No

How would you describe your pain?*

Does your pain radiate?*

Does anything make your pain worse?*

Does anything improve your pain?*

Is there tingling/numbness?*

Yes

No

Is there swelling in the area?*

Yes

No

Is the pain worse with movement?*

Yes

No

Are you currently taking medications for this?*

Yes

No

Information about your LOW BACK pain:

Have you ever had surgery on this area?*

Yes

No

Is this pain the result of a major trauma or accident?*

Yes

No

Does your pain prevent you from doing daily activities?*

Yes

No

How would you describe your pain?*

Does your pain radiate?*

Does anything make your pain worse?*

Does anything improve your pain?*

Is there tingling/numbness?*

Yes

No

Is there swelling in the area?*

Yes

No

Is the pain worse with movement?*

Yes

No

Are you currently taking medications for this?*

Yes

No

Information about your SHOULDER pain:

Which side is your pain?*

Left

Right

Both

Have you ever had surgery on this area?*

Yes

No

Is this pain the result of a major trauma or accident?*

Yes

No

Does your pain prevent you from doing daily activities?*

Yes

No

How would you describe your pain?*

Does your pain radiate?*

Does anything make your pain worse?*

Does anything improve your pain?*

Is there tingling/numbness?*

Yes

No

Is there swelling in the area?*

Yes

No

Is the pain worse with movement?*

Yes

No

Are you currently taking medications for this?*

Yes

No

Information about your ELBOW pain:

Which side is your pain?*

Left

Right

Both

Have you ever had surgery on this area?*

Yes

No

Is this pain the result of a major trauma or accident?*

Yes

No

Does your pain prevent you from doing daily activities?*

Yes

No

How would you describe your pain?*

Does your pain radiate?*

Does anything make your pain worse?*

Does anything improve your pain?*

Is there tingling/numbness?*

Yes

No

Is there swelling in the area?*

Yes

No

Is the pain worse with movement?*

Yes

No

Are you currently taking medications for this?*

Yes

No

Information about your HAND pain:

Which side is your pain?*

Left

Right

Both

Have you ever had surgery on this area?*

Yes

No

Is this pain the result of a major trauma or accident?*

Yes

No

Does your pain prevent you from doing daily activities?*

Yes

No

How would you describe your pain?*

Does your pain radiate?*

Does anything make your pain worse?*

Does anything improve your pain?*

Is there tingling/numbness?*

Yes

No

Is there swelling in the area?*

Yes

No

Is the pain worse with movement?*

Yes

No

Are you currently taking medications for this?*

Yes

No

Information about your ARM pain:

Which side is your pain?*

Left

Right

Both

Have you ever had surgery on this area?*

Yes

No

Is this pain the result of a major trauma or accident?*

Yes

No

Does your pain prevent you from doing daily activities?*

Yes

No

How would you describe your pain?*

Does your pain radiate?*

Does anything make your pain worse?*

Does anything improve your pain?*

Is there tingling/numbness?*

Yes

No

Is there swelling in the area?*

Yes

No

Is the pain worse with movement?*

Yes

No

Are you currently taking medications for this?*

Yes

No

Information about your WRIST pain:

Which side is your pain?*

Left

Right

Both

Have you ever had surgery on this area?*

Yes

No

Is this pain the result of a major trauma or accident?*

Yes

No

Does your pain prevent you from doing daily activities?*

Yes

No

How would you describe your pain?*

Does your pain radiate?*

Does anything make your pain worse?*

Does anything improve your pain?*

Is there tingling/numbness?*

Yes

No

Is there swelling in the area?*

Yes

No

Is the pain worse with movement?*

Yes

No

Are you currently taking medications for this?*

Yes

No

Information about your HIP pain:

Which side is your pain?*

Left

Right

Both

Have you ever had surgery on this area?*

Yes

No

Is this pain the result of a major trauma or accident?*

Yes

No

Does your pain prevent you from doing daily activities?*

Yes

No

How would you describe your pain?*

Does your pain radiate?*

Does anything make your pain worse?*

Does anything improve your pain?*

Is there tingling/numbness?*

Yes

No

Is there swelling in the area?*

Yes

No

Is the pain worse with movement?*

Yes

No

Are you currently taking medications for this?*

Yes

No

Information about your LEG pain:

Which side is your pain?*

Left

Right

Both

Have you ever had surgery on this area?*

Yes

No

Is this pain the result of a major trauma or accident?*

Yes

No

Does your pain prevent you from doing daily activities?*

Yes

No

How would you describe your pain?*

Does your pain radiate?*

Does anything make your pain worse?*

Does anything improve your pain?*

Is there tingling/numbness?*

Yes

No

Is there swelling in the area?*

Yes

No

Is the pain worse with movement?*

Yes

No

Are you currently taking medications for this?*

Yes

No

Information about your KNEE pain:

Which side is your pain?*

Left

Right

Both

Have you ever had surgery on this area?*

Yes

No

Is this pain the result of a major trauma or accident?*

Yes

No

Does your pain prevent you from doing daily activities?*

Yes

No

How would you describe your pain?*

Does your pain radiate?*

Does anything make your pain worse?*

Does anything improve your pain?*

Is there tingling/numbness?*

Yes

No

Is there swelling in the area?*

Yes

No

Is the pain worse with movement?*

Yes

No

Are you currently taking medications for this?*

Yes

No

Information about your ANKLE pain:

Which side is your pain?*

Left

Right

Both

Have you ever had surgery on this area?*

Yes

No

Is this pain the result of a major trauma or accident?*

Yes

No

Does your pain prevent you from doing daily activities?*

Yes

No

How would you describe your pain?*

Does your pain radiate?*

Does anything make your pain worse?*

Does anything improve your pain?*

Is there tingling/numbness?*

Yes

No

Is there swelling in the area?*

Yes

No

Is the pain worse with movement?*

Yes

No

Are you currently taking medications for this?*

Yes

No

Information about your FOOT pain:

Which side is your pain?*

Left

Right

Both

Have you ever had surgery on this area?*

Yes

No

Is this pain the result of a major trauma or accident?*

Yes

No

Does your pain prevent you from doing daily activities?*

Yes

No

How would you describe your pain?*

Does your pain radiate?*

Does anything make your pain worse?*

Does anything improve your pain?*

Is there tingling/numbness?*

Yes

No

Is there swelling in the area?*

Yes

No

Is the pain worse with movement?*

Yes

No

Are you currently taking medications for this?*

Yes

No

Narcotic addiction treatment

Do you have a history of narcotic abuse/opioid use?*

Yes

No

How long have you been on treatment for this condition?*

Never

Days

Months

Years

Are you currently experiencing any symptoms of withdrawal?*

Are you currently receiving counseling*

Yes

No

Anxiety Questionnaire

How long have you experienced these symptoms?*

Days

Weeks

Months

Years

Currently taking medications?*

Yes

No

How often do you experience these symptoms?*

Constant

Frequent

Infrequent

Check all of the symptoms you feel when you are anxious:*

Please choose any associated conditions you have:*

What makes your anxiety worse?*

What relieves your anxiety?

Rest

psychotherapy

cognitive behavioral therapy

relaxation techniques

ADD/ADHD Questionnaire

What behavioral problems are you experiencing?*

Cannot concentrate

impulsive

aggression

foul language

Do you have associated hyperactivity?*

Yes

No

Do you have difficulty concentrating?*

Yes

No

Are you easily distracted?*

Yes

No

Do these symptoms affect your daily routine?*

Yes

No

Are you currently taking medication for ADD/ADHD?*

Yes

No

Request An Appointment

Pain Management Patient Registration

Pain Management Questionnaire

Information about your HEAD pain:

Information about your NECK pain:

Information about your MIDDLE BACK pain:

Information about your LOW BACK pain:

Information about your SHOULDER pain:

Information about your ELBOW pain:

Information about your HAND pain:

Information about your ARM pain:

Information about your WRIST pain:

Information about your HIP pain:

Information about your LEG pain:

Information about your KNEE pain:

Information about your ANKLE pain:

Information about your FOOT pain:

Narcotic addiction treatment

Anxiety Questionnaire

ADD/ADHD Questionnaire

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