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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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: ______________________________________________________________________________