Download HAMID MOAYAD, D.O., P.A. NEUROLOGY CONFIDENTIAL

HAMID MOAYAD, D.O., P.A.
NEUROLOGY
AMERICAN ACADEMY OF NEUROLOGY
AMERICAN COLLEGE OF NEUROPSYCHIATRY
AMERICAN SOCIETY OF NEUROIMAGING
CONFIDENTIAL
PATIENT AGENDA
Dear Patient:
To help you make best use of your time with Dr. Moayad, please list the questions you
would like to discuss during your appointment.
1. __________________________________________________________________________
____________________________________________________________________________
2. __________________________________________________________________________
____________________________________________________________________________
3. __________________________________________________________________________
____________________________________________________________________________
4. __________________________________________________________________________
____________________________________________________________________________
5. __________________________________________________________________________
____________________________________________________________________________
_________________________________________
Signature
_________________________________________
Date
MEDICATION
PATIENT FOLLOW UP FORM
Date: ________________
1. ANTIBIOTICS:
NAME
Name: __________________________________
STRENGTH
____________________ ________________
____________________ ______________
2. PAIN MEDS:
______________
______________
FREQUENCY
Herxheimers
______________ Effective
Herxheimers
______________ Effective
______________ ______________
______________ ______________
3. ANTI INFLAMMATORY:
______________
______________ ______________
______________
______________ ______________
______________
______________ ______________
4. ANTI DEPRESSANT:
______________
______________
______________
______________
______________
______________
______________
______________
5. ANTI SEIZURE
______________
______________
______________
______________
6. OTHER MEDICATIONS:
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
Yes
Yes
Yes
Yes
No
No
No
No
LYME PATIENT FOLLOW UP FORM
Date: ______________
Name: ___________________________
Please circle on a scale of 0 through 4.
0 being not present and 4 meaning severe symptoms:
None
Minimal
Mild
1. Chills or mild fever …………………….………………..……
0
1
2
2. Sore Throat ……….…………………………………………..…
0
1
2
3. Lymph node pain ………..…………………………………...
0
1
2
4. Muscle weakness …………………………………………….
0
1
2
5. Muscle pain………………………………………………….......
0
1
2
6. Headaches ……..…………………………………………………
0
1
2
7. Joint pain ………………………………………………………….
0
1
2
Specify which joints: _____________________________________
______________________________________________________
Does joint pain move around? Yes 
Moderate
Severe
3
3
3
3
3
3
3
4
4
4
4
4
4
4
No 
8. Neurological symptoms
Light bothers eyes ……………………………………..
Forgetfulness ……..………………………..…………..
Irritability …………………………………………………..
Confusion; difficulty thinking..……………………..
Depression ………….…………………………………..…
Inability to concentrate .……………………………..
Brief periods of visual spots or loss of vision..
0
0
0
0
0
0
0
1
1
1
1
1
1
1
2
2
2
2
2
2
2
3
3
3
3
3
3
3
4
4
4
4
4
4
4
9. Sleep disturbance ……………….………………………………
0
1
2
3
4
0
1
2
3
4
Worse

Too Much  Too Little

10. Fatigue ………………………………………………..
Since my last visit I feel: Same

Better

Patient Comfort Assessment Guide
Name: ____________________________________________ Date: ______________________
1. Where is your pain? ______________________________________________________________
2. Circle the words that describe your pain.
aching
sharp
penetrating
throbbing
tender
nagging
shooting
burning
numb
stabbing
exhausting
miserable
gnawing
tiring
unbearable
Circle One
Occasional
Continuous
What time of day is your pain the worst? Circle one.
Morning
afternoon
evening
nighttime
3. Rate your pain by circling the number that best describes your pain at its worst in the last month.
No Pain 0 1 2 3 4 5 6 7 8 9 10
Pain as bad as you can imagine
4. Rate your pain by circling the number that best describes your pain at its least in the last month.
No Pain 0 1 2 3 4 5 6 7 8 9 10
Pain as bad as you can imagine
5. Rate your pain by circling the number that best describes your pain at its average in the last month.
No Pain 0 1 2 3 4 5 6 7 8 9 10
Pain as bad as you can imagine
6. Rate your pain by circling the number that best describes your pain right now.
No Pain 0 1 2 3 4 5 6 7 8 9 10
Pain as bad as you can imagine
7. What makes your pain better? _____________________________________________________
8. What makes your pain worse? _____________________________________________________
9. What treatments or medicines are you receiving for your pain? Circle the number to describe the amount
of relief the treatment or medicine provide(s) you.
a) _____________________________________ No 0 1 2 3 4 5 6 7 8 9 10 Complete
Treatment or Medicine (include dose)
Relief
Relief
b) _____________________________________ No 0 1 2 3 4 5 6 7 8 9 10 Complete
Treatment or Medicine (include dose)
Relief
Relief
c) _____________________________________ No 0 1 2 3 4 5 6 7 8 9 10 Complete
Treatment or Medicine (include dose)
Relief
Relief
d) _____________________________________ No 0 1 2 3 4 5 6 7 8 9 10 Complete
Treatment or Medicine (include dose)
Relief
Relief
10. What side effects or symptoms are you having? Circle the number that best describes your experience
during the past week.
a. Nausea
b. Vomiting
c. Constipation
d. Lack of Appetite
e. Tired
f. Itching
g. Nightmares
h. Sweating
i. Difficulty Thinking
j. Insomnia
Barely
Noticeable
Barely
Noticeable
Barely
Noticeable
Barely
Noticeable
Barely
Noticeable
Barely
Noticeable
Barely
Noticeable
Barely
Noticeable
Barely
Noticeable
Barely
Noticeable
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
Severe Enough
to Stop Medicine
Severe Enough
to Stop Medicine
Severe Enough
to Stop Medicine
Severe Enough
to Stop Medicine
Severe Enough
to Stop Medicine
Severe Enough
to Stop Medicine
Severe Enough
to Stop Medicine
Severe Enough
to Stop Medicine
Severe Enough
to Stop Medicine
Severe Enough
to Stop Medicine
11. Circle the one number that describes how during the past week pain has interfered with your:
a. General Activity
Does Not
0 1 2 3 4 5 6 7 8 9 10
Completely
Interfere
Interferes
b. Mood
Does Not
0 1 2 3 4 5 6 7 8 9 10
Completely
Interfere
Interferes
c. Normal Work
Does Not
0 1 2 3 4 5 6 7 8 9 10
Completely
Interfere
Interferes
d. Sleep
Does Not
0 1 2 3 4 5 6 7 8 9 10
Completely
Interfere
Interferes
e. Enjoyment of Life
Does Not
0 1 2 3 4 5 6 7 8 9 10
Completely
Interfere
Interferes
f. Ability to Concentrate
Does Not
0 1 2 3 4 5 6 7 8 9 10
Completely
Interfere
Interferes
g. Relations with
Does Not
0 1 2 3 4 5 6 7 8 9 10
Completely
Other People
Interfere
Interferes
Purdue: committed to managed care
Prepared by Elizabeth J. Narcessian, M.D., Clinical Chief of Pain Management, Kessler Institute for Rehanilitation, Inc
B5375 OOMC59 6/01
Medication Log
Patient _____________________________________ Birthdate __________________
Phone _______________ Cell Phone _____________ Occupation ________________
Medical/Allergy
Alerts:
Pharmacy___________________________________ Pharmacy Phone ____________
Date
Rx
Medication
Dosage
Qty. Freq.
Refill
1
Refill
2
Refill
3
Refill
4
Stop Date
Notes: _______________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Antibiotics for Lyme Disease
Patient _______________________________________________ Birth Date ______________________
Date
Antibiotic
Antifungal
Stomach
Protectant
Herxheimer’s
Reaction
Adverse Effect
Problem List
Patient ___________________________________________ Birth Date ________________________
Prob.
No.
Date
Noted
Problem
ICD-9
Code
Date
Resolved
HAMID MOAYAD, D.O. ,P.A.
NEUROLOGY
AMERICAN ACADEMY OF NEUROLOGY
AMERICAN COLLEGE OF NEUROPSYCHIATRY
AMERICAN SOCIETY OF NEUROIMAGING
RECORDS RELEASE AUTHORIZATION
TO:
Dr./Facility:
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
Patient Name: ______________________________________________, hereby requests that
you release to: ___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
A report of my diagnosis, treatment, prognosis and recommendations, as well as other data pertinent
to your treatment of me from _________________________ to ____________________.
Date of Request: _______________
Patient’s Signature __________________________
Witness: ______________________
Date of Birth
_____________________________
Address: __________________________________
City, ST, Zip ________________________________
Consultation, EMG, NCV, EEG, Ambulatory EEG, Evoked Potentials
1305 Airport FWY, Suite 311, Bedfort, TX 76021 * Phone (817) 540-3388 Fax (817) 540-6176
Lyme Symptom Check List
Patient _______________________________________________ Birth Date ______________________
Risk Profile (Please Check)
Infested Area ____
Frequent Outdoor Activities ____
Fishing ____ Hiking ____ Camping ____ Gardening ____ Hunting ____ Ticks Noted on Pets ____
Do you remember being bitten by a tick? No ____ Yes ____ When? ______________________
Do you remember having the “Bull’s Eye Rash”? No ____ Yes ____ Any other rash? No ____ Yes ____
Have you had any of the following? Check all “YES” Answers
Unexplained Skin Changes:
Fevers ____
Sweats ____ Chills ____
Flushing ____
Unexplained Weight Change:
Weight Loss ____
Weight Gain ____
Fatigue ____
Tiredness ____
Unexplained Hair Loss ____
Swollen Glands ____
Sore Throat ____
Testicular Pain ____
Pelvic Pain ____
Unexplained Menstrual Irregularity ____
Unexplained Milk Production ____ Unexplained Breast Pain ____
Urinary Problems: Irritable Bladder ____ Bladder Dysfunction ____
Sexual Difficulties: Sexual Dysfunction ____ Loss of Libido (desire) ____
Change in Bowel Function: Constipation ____ Diarrhea ____ Upset Stomach ____
Chest Pain ____ Rib Soreness ____
Shortness of Breath ____ Cough ____
Heart Palpations ____ Pulse Skips ____ Heart Block ____
Any history of heart murmur or valve prolapse? Yes ____ No ____
Joint pain or swelling? Yes ____ No ____ List joints: _____________________________________
Stiffness: Joints ____ Neck ____ Back ____
Muscle Pain ____ Cramps ____
Twitching: Face ____ Other Muscles __________________________________________________
Headache ____
Neck Creaks ____ Neck Cracks ____ Neck Stiffness _____
Tingling ____ Numbness ____ Burning _____ Stabbing Sensations ____
Facial Paralysis (Bells Palsy) ____
Eyes/Vision: Double Vision ____ Blurry ____ Pain ____ Increased Floaters ____
Ears/Hearing: Buzzing ____ Ringing ____ Ear Pain ____
Increased Motion Sickness ____ Vertigo ____
Lightheadedness ____ Wooziness ____ Poor Balance ____ Difficulty Walking ____
Tremor ____
Confusion ____ Difficulty Thinking ____
Difficulty with Concentration ____Difficulty Reading ___ Forgetfulness ___ Poor Short Term Memory ___
Disorientation (Getting Lost) ____ Going to Wrong Places ___ Difficulty with Speech ___ Difficulty Writing ___
Mood Swings ____ Irritability ____ Depression ____
Disturbed Sleep: Too Much ____ Too Little ____ Early Awakening ____
Exaggerated Symptoms or Worse Hangover from Alcohol ____
INFORMED CONSENT FOR TREATMENT OF PERSISTENT LYME DISEASE
There is considerable uncertainty regarding the diagnosis and treatment of Lyme disease. No single diagnostic
and treatment program for Lyme disease is universally successful or accepted. Medical opinion is divided, and
two schools of thought regarding diagnosis and treatment exist. Each of the two schools of thought is
described as peer-reviewed, evidence-based treatment guidelines. Until we know more, patients must weigh
the risks and benefits of treatment in consultation with their doctor.
My Diagnosis. The diagnosis of Lyme disease is primarily a clinical determination made by my doctor based on
my exposure to ticks, my report of symptoms, and my doctor’s observations of signs of the disease, with
diagnostic tests playing a supportive role.
Doctors differ in how they diagnose Lyme disease.


Some physicians rely on the narrow surveillance case criteria of the CDC for clinical diagnosis even
though the CDC itself cautions against this approach. These physicians may fail to diagnose some
patients who actually have Lyme disease. For these patients, treatment will either not occur or will be
delayed.
Other physicians use broader clinical criteria for diagnosing Lyme disease. These physicians believe it
is better to err on the side of treatment because of the serious consequences of failing to treat active
Lyme disease. These physicians sometimes use the antibiotic responsiveness of a patient to assist in
their diagnosis. Since no treatment is risk-free, use of broader clinical criteria to diagnose disease
could in some cases expose patients to increased treatment complications. This approach may result
in a tendency to over diagnose and over treat Lyme disease.
My Treatment Choices.
The medical community is divided regarding the best approach for treating
persistent Lyme disease. At this time the majority of physicians follow the treatment guidelines of the
Infectious Disease Society of America, which recommends short-term treatment only and views the long-term
effects of Lyme disease as an autoimmune process or permanent damage that is unaffected by antibiotics.
Other physicians believe that the infection persists, is difficult to eradicate, and therefore requires long-term
treatment with intravenous, intramuscular, or oral antibiotics, frequently in high and/or combination doses.
Potential Benefits of Treatment.
Some clinical studies support longer term treatment
approaches, while others do not. The experience in this office is that although most patients improve with
continued treatment, some do not.
Risks of Treatment.
There are potential risks involved in using any treatment, just as there are in
foregoing treatment entirely. Some of the problems with antibiotics may include (a) allergic reactions, which
may manifest as rashes, swelling, and difficulty breathing, (b) stomach or bowel upset, or (c) yeast infections.
Severe allergic reactions may require emergency treatments, while other problems may require suspension of
treatment, or adjustment of medication. Other problems such as adverse effects on liver, kidney, gallbladder,
or other organs may occur.
Factors to Consider in My Decision.
No one knows the optimal treatment of symptoms that persist after a
patient is diagnosed with Lyme disease and treated with a simple short course of antibiotic therapy. The
appropriate treatment may be supportive therapy without the administration of any additional antibiotics.
Or, the appropriate treatment might be additional antibiotic therapy. If additional antibiotic therapy is
warranted, no one knows for certain exactly how long to give the additional therapy. By taking antibiotics for
longer periods of time, I place myself at greater risk of developing side effects. By stopping antibiotic
treatment, I place myself at greater risk that a potential serious infection will progress. Antibiotics are the
only form of treatment shown to be effective for Lyme disease, but not all patients respond to antibiotic
therapy. There is no currently available diagnostic test that can demonstrate the eradication of the Lyme
bacteria from my body. Other forms of treatment designed to strengthen my immune system also may be
important. Some forms of treatment are only intended to make me more comfortable by relieving my
symptoms and do not address any underlying infection.
My decision about continued treatment may depend on a number of factors and the importance of these
factors to me. Some of these factors include (a) the severity of my illness and degree to which it impairs my
quality of life, (b) whether I have co-infections, which can complicate treatment, (c) my ability to tolerate
antibiotic treatment and the risk of major and minor side effects associated with the treatment, (d) whether I
have been responsive to antibiotics in the past, (e) whether I relapse or my illness progresses when I stop
taking antibiotics, and (f) my willingness to accept the risk that, left untreated, a bacterial infection potentially
may get worse.
For example, if my illness is severe, significantly affects my quality of life, and I have been responsive to
antibiotic treatment in the past, I may wish to continue my treatment. However, if I am willing to accept the
risk that the infection may progress or if I am not responsive to antibiotics, I may wish to terminate treatment.
I will ask my doctor if I need any more information to make this decision and am aware that I have the right to
obtain a second opinion if I think this would be helpful.
My questions have all been answered in terms I understand. I am aware of the risks involved in antibiotic and
in foregoing antibiotic treatment. Based on this information, I have decided: (CHECK ONE)
 To treat my Lyme disease with antibiotics
until my clinical symptoms resolve

Not to pursue antibiotic therapy
 Only to treat my Lyme disease with antibiotics
for thirty days, even if I still have symptoms.
To my knowledge, I am not allergic to any medications except those listed below:
_____________________________________________________________________________
I understand the benefits and risks of the proposed course of treatment and of the alternatives to it, including
the risks and benefits of foregoing treatment altogether. My questions have all been answered in terms I
understand. All blanks on this document have been filled in as of the time of my signature.
Signature: _________________________________
Date: ________________________________
Print Name: ________________________________
Witness: _____________________________
Hamid Moayad, D.O., P.A. Neurology
Patient Registration Form, Please Print
Date: _____________________________
Name: ____________________________
Home Addres: ______________________
City: ______________________________
Drivers License # _________________________
Date of Birth__________ Age ____ Sex ______
Phone Number __________________________
State: ______________________ Zip ________
Spouse or Parent Name: _________________________________ Marital Status ___________________
Name and Address of Employer __________________________________________________________
Name and Address of Spouse Employer ____________________________________________________
Social Security: __________________ Spouse SS# ____________________________________________
Type of Ins: ___ Group ____ HMO ___ PPO __ Champus ____ Medicare/Medicaid ____ W/C _________
Primary Insurance Company Name: ________________________________________________________
Insurance Company Address: _____________________________________________________________
Insured Name: _________________________________________________________________________
Insured Employer: ______________________________________________________________________
Policy # _______________________________________________________________________________
Secondary Insurance Company Name: ______________________________________________________
Insurance Company Address: _____________________________________________________________
Insured Name: _________________________________________________________________________
Insured Employer: ______________________________________________________________________
Policy # _______________________________________________________________________________
Workers Comp _________________________________________________________________________
Date of Accident ________________________ Employer: ______________________________________
Employer Address: ______________________________________________________________________
How Injury Occurred: ____________________________________________________________________
Medicare # ____________________________________________________ Part A ______ Part B ______
Referred by DR: ________________________________________________________________________
Health History:
Medical Allergies
High Blood Pressure Yes ____ No ____ ____________________________
Diabetes
Yes ____ No ____ ____________________________
Prolonged Bleeding Yes ____ No ____ _____________________________
Easy Bruising
Yes ____ No ____ ____________________________
Pregnant Now
Yes ____ No ____ _____________________________
Medications Taking Now
____________________
____________________
____________________
____________________
____________________
Significant Medical/Surgery History:
Reasons for Seeking Medical Attention:
_______________________________________________
__________________________________
_______________________________________________
__________________________________
_______________________________________________
__________________________________
_______________________________________________
__________________________________
_______________________________________________
__________________________________
I hereby assign all my medical benefits, including Major Medical, PIP, Medicare, Private Insurance and any
other health plans to Hamid Moayad, D.O. , P.A. I hereby authorize said assignee to release all information
necessary to secure payment. I understand that I am financially responsible for all charges. All payments to
be made to Hamid Moayad, D.O., 1305 Airport Freeway, Suite 311, Bedford, Texas, 76021.
Patient or Guardian Signature _______________________________________________________________
DR MOAYAD IS AN OUT OF NETWORK PROVIDER FOR PPO INSURANCES
OFFICE POLICY: We appreciate your patronage. The purpose of our policy is to inform patients of their
responsibility before their appointment. If you do not understand any part of the policy below, please ask our
office staff.
Release of Medical Information:
I hereby authorize Hamid Moayad, D.O., P.A. to furnish information to my insurance carriers, physicians and
other facilities concerning my illness and treatments. I certify that I have given correct and complete
information with regards to my insurance coverage.
Assignment of Benefits:
I hereby assign Hamid Moayad, D.O., P.A. all payments for medical services rendered. I understand that I am
responsible for any amount not paid by my insurance company, including diagnostics services, evaluation,
laboratory tests, non-covered services, copays, deductibles, and co insurance balances.
Insurance Policy:
It is the policy of this office to collect copays and deductables at the time of your appointment. It may also be
necessary to collect payment in full for some lab services. (Lyme Igenex Testing) that is not covered by
insurance.
If for any reasons you cannot pay at the time of service, you may notify the office so we may set up a payment
option plan for you. If you do not call the office if you cannot make your appointment, a fee will be applied to
that date of service and will be due at your next appointment.
In the event that you give our office out-dated information and payment is subsequently denied or withheld,
you are responsible for payment of outstanding balances after an attempt to file the correct information.
Referrals:
If you insurance company requires you to have a referral, it is your responsibility to make sure our office has
an active referral at the time of your visit. This includes in network referrals.
General Consent to Treat:
I authorize and direct Hamid Moayad, D. O., P.A. to treat my medical condition in the way they may determine
advisable for my well being. I acknowledge that the practice of medicine is not an exact science and no
guarantees have been made to me as to the outcome of my treatment.
Date and sign that you understand our office policy, release of medical information, assignment of benefits,
referrals, insurance policy, and general consent to treat.
Patient Signature: ______________________________________________________________________
Guardian Signature: _____________________________________________________________________
Witness: ______________________________________________________________________________