Download patient registration - Neurology Associates, PC

PATIENT REGISTRATION
NEUROLOGY ASSOCIATES, P.C.
DATE________________
Patient’s Name(Last)_____________________________(First)________________________(M.I.)_______
Responsible Party if Under Age 18:_________________________Race_________Ethnicity____________
SSN:__________________________
Sex: Male____Female_____ Birth Date:______________________
Marital Status: Single________Married________Divorced_______Widowed_______Separated________
Street/Billing Address:_____________________________________________________________________
City:_______________________________________State:_____________Zip:______________-_________
Home Phone:__________________Cell Phone:____________________Work Phone:__________________
Occupation:___________________________Employer’s Name:___________________________________
Referring Physician:__________________________Primary Care Physician:________________________
What is the reason for your evaluation today?__________________________________________________
What is your preferred pharmacy?___________________________________________________________
List any medication allergies:________________________________________________________________
Do you have an allergy to Latex? Yes_____No_____ Preferred Spoken Language___________________
PRIMARY CONTACT PERSON (SPOUSE, PARENT, SIGNIFICANT OTHER, ETC.)
Name:__________________________________Relationship:___________________DOB:______________
Address:__________________________________________________Employer:______________________
Home Phone:____________________Cell Phone:__________________Work Phone:__________________
____Yes____No I give the physicians/staff of NAPC permission to discuss my medical information with this individual.
ASSIGNMENT OF BENEFITS AND AUTHORIZATION TO RELEASE MEDICAL INFORMATION
I hereby assign all medical benefits, to include major medical benefits to which I am entitled, including Medicare, private insurance, and any other
health plan to Neurology Associates, P.C. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to
be considered as valid as the original. I understand that I am financially responsible for all charges whether or not paid by said insurance. Should it
become necessary to turn my account over to an outside collection agency, I will be responsible for collection costs, attorney fees, litigation fees, and
court costs. I hereby authorize Neurology Associates, P.C. and its employees and agents TO RELEASE ALL INFORMATION, reports, and records
if necessary for the purposes of treatment, payment and healthcare operations, including a discussion of my medical condition, to the insurance
provider, rehabilitation provider, employer, hospitals, and doctors. If I have a liability injury, I understand that I have the option of using my health
insurance, if available, or I will be expected to pay for treatment.
I acknowledge that I have been offered a copy of Neurology Associates, P.C. Notice of Privacy Practice Policy, which describes how
my health insurance information may be used or disclosed.
Signature:_________________________________________________Date:__________________________
Responsible Person if Patient is a Minor:___________________________________Date:______________
Form NA 99-1
Name_________________________ Date:_____________
SOCIAL HISTORY
Marital Status: Are you currently married? ______No ______Yes
Education: How many years of school have you completed?_______
Occupation: Your current employment status: ______Retired ______Homemaker ______Employed
Current Occupation(s):___________________________________
Are you disabled? ______No ______Yes Applying for disability? _____No _____Yes
MEDICATIONS
Please list any medications you are currently taking including any prescription and/or non-prescription
medications including vitamins, nutritional supplements, oral contraceptives, pain relievers, etc.
Name of Medication
Dose
How often Taken
(Please attach additional paper if more space is needed)
ALLERGIES
Please list any medications for which you have had an allergic reaction (hives, skin rash, breathing problems,
etc.)
Name of Medication
Describe Allergic Reaction
Have you had an allergic reaction to: Iodine or X-ray contrast dye? ____No ____Yes
Do you have an allergy to Latex? ____No ____Yes
Initial_______
Page 1
Form NA 99-1
Name_________________________ Date:_____________
Have you ever used any of the following substances?
Substance
Currently
use?
Previously
used?
Caffeine
_____ Yes
_____ No
_____ Yes
_____ No
Tobacco
_____ Yes
_____ No
_____ Yes
_____ No
Alcohol
_____ Yes
_____ No
_____ Yes
_____ No
Recreational/
Street Drugs
_____ Yes
_____ No
_____ Yes
_____ No
Type/Amount/Frequency
How
Long?
(Years)
When
Stopped?
FAMILY HISTORY
Family
Members
Father
Living?
Present Health
Cause of Death
Age
_____ Yes
_____ No
Mother
_____ Yes
_____ No
Brother(s)
_____ Yes
_____ No
Sister(s)
_____ Yes
_____ No
Circle any illnesses that have occurred in your blood relatives:
Cancer
Heart Disease
Asthma
Stroke
Diabetes
Blackouts
Kidney Disease
Seizures
Migraines
High cholesterol
Tremor
Mental disorder
Nervous Disorder
High blood pressure
Thyroid
Other Hereditary diseases________________________________________________________________
Initial_______
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Form NA 99-1
Name_________________________ Date:_____________
REVIEW OF SYSTEMS
Please indicate whether you have experienced the following symptoms during recent months, unless otherwise specified, by
checking “No” or “Yes” for each question. Circle the symptoms(s) you have experienced when multiple symptoms are
listed in a question.
1)
2)
3)
4)
Skin rash, sore, excessive bruising or change of a mole?
Excessive thirst or urination?
Change in sexual drive or performance?
Significant headaches, seizures, slurred speech or
difficulty moving an arm or leg?
5) Eye problems such as double or blurred vision,
cataracts, or glaucoma?
6) Diminished hearing, dizziness, hoarseness or sinus
problems?
7) Bothered with cough, shortness of breath, wheezing,
or asthma?
8) Coughing up sputum or blood?
9) Exposed to anyone with tuberculosis?
10) ‘Blacked out’ or lost consciousness?
11) Chest pain or pressure, rapid or irregular heart beats,
or known difficulty with a heart valve?
12) Awakening at night with shortness of breath?
13) Abnormal swelling in the legs or feet?
14) Pain in the calves or your legs when you walk?
15) Difficulty with swallowing, heartburn, nausea,
vomiting, or stomach trouble?
16) Significant problems with bowel movements (i.e.
constipation, diarrhea, or blood in the stool)?
17) Difficulty starting your urinary stream, completely
emptying your bladder, or leaking urine?
18) Burning or pain when urinating?
19) Pain, stiffness, or swelling in your back, joints,
or muscles?
20) Fever within the last month?
21) Enlarged glands (lymph nodes)?
22) Feel you are at risk for HIV or AIDS?
23) Immunized for influenza, tetanus/diphtheria and/or
pneumonia within the last year?
24) Experiencing an unusually stressful situation?
25) Weight gain or loss of more than 10 lbs during the
last 6 months?
26) Problems falling asleep, staying asleep, sleep apnea,
or disruptive snoring?
27) Abnormal nipple discharge or breast lump?
28) Have you ever felt a need to cut down on your alcohol
consumption?
29) Do relatives/friends worry or complain about your
alcohol consumption?
30) Have you been physically, sexually, or emotionally
No
Yes
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Form NA 99-1
abused?
Initial_______
Name_________________________ Date:_____________ Page 3
PAST MEDICAL HISTORY
Have you had any of the following conditions?
No
Yes
Space below for physicians use
1) Abnormal chest X-ray
2) Anxiety, depression, or mental illness
3) Blood problems (abnormal bleeding, anemia,
high or low white count)
4) Diabetes
5) High blood pressure
6) High cholesterol or triglycerides
7) Stroke or TIA
8) Heart problems (MI, arrhythmia, pacer)
9) Treatment for alcohol or drug abuse
10) Tuberculosis or positive TB skin test
11) Growth removed from the colon or rectum
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2) _______________________
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9) _______________________
10) ______________________
11) ______________________
Please indicate whether you have ever had a medical problem and/or surgery related to each of the following by
placing a check mark in the appropriate box(es). If you have had surgery, indicate the approximate year(s) of
surgery. Circle the appropriate choice when multiple choices are listed in a question.
No
problem
Medical
problem
Surgery
Year of
surgery
Space for physicians use
1) Eyes (cataracts, glaucoma)
2) Ears, nose, sinuses, or tonsils
3) Thyroid or parathyroid glands
4) Heart valves or abnormal rhythm
5) Arteries (aorta, arteries to the
head, arms, or legs)
6) Veins or blood clots
7) Lungs
8) Esophagus or stomach (ulcer)
9) Bowel (small and large intestine)
appendix, or hernia
10) Liver or gallbladder disease
11) Pancreas
12) Lymph nodes or spleen
13) Kidney or bladder
14) Bones, joints, or muscles
15) Back, neck, or spine
16) Brain
17) Skin
18) Breasts
19) Females: uterus, tubes, ovaries
20) Males: prostate, penis, testes,
vasectomy
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14)__________________
15)__________________
16)__________________
17)__________________
18)__________________
19)__________________
20)__________________
Form NA 99-1
Page 4
Initial_______
Name_________________________ Date:_____________
NEUROLOGIC REVIEW
Please circle the appropriate response.
Handedness: Right or Left
Indicate whether you have experienced the following symptoms during recent months by checking ‘No’ or
‘Yes' for each question. Circle the symptoms you have experienced when multiple symptoms are listed.
1)
2)
3)
4)
5)
Headache, nausea, vomiting
History of seizures or blackouts
Numbness, tingling, pain
Weakness, cramps, muscle twitching
Difficulty walking, incoordination,
Involuntary movements
6) Change in vision, hearing, taste, or smell
7) Double vision, drooping of the eyelids
8) Dizziness, lightheadedness, vertigo,
ringing in the ears
9) Difficulty with speech or swallowing
10) Difficulty with bowel or bladder control
11) Difficulty with memory, change in
behavior or mood
12) Difficulty sleeping, loss of appetite,
weight loss or gain
No
Yes
Space below for physicians
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11) ___________________
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12) ___________________
13) Have you had any of the procedures performed listed below? If so, when and where?
CT Scan
MRI Scan
Myelogram
Carotid dopplers
EEG
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PHYSICIAN SIGNATURE
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