Neuro-Opthamalogy. USF Eye Institute and Ear, Nose and Throat Center. Dear Neuro-ophthalmology Patients:

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1 USF Eye Institute and Ear, Nose and Throat Center Neuro-Opthamalogy Dear Neuro-ophthalmology Patients: The following information is to prepare you for your visit with Dr. Drucker. If you have had an MRI, MRA, CT scan, sleep studies, EKG, Holter-monitor, or lab work, please have the results faxed to Dr. Drucker's attention at (813) prior to your appointment. Follow up Appointments: Please make sure your follow-up appointment with Dr. Drucker is at least 4-5 business days after your testing appointment(s) to allow the testing facility to process a report, unless otherwise instructed by Dr. Drucker. Please note that Dr. Drucker does not give any test results over the phone. Please make a follow-up appointment by calling (813)

2 USF Eye Institute and Ear, Nose and Throat Center Neuro-Opthamalogy Appointment Date and Time: Provider: NOTICE TO ALL PATIENTS Thank you for choosing the USF Eye Institute and Ear, Nose and Throat Center for your medical needs. When you arrive for your visit you will be given a parking permit to place on the inside windshield of your vehicle. Placing this permit represents you having an appointment in the USF Eye Institute or the Ear, Nose and Throat Center and will protect you from getting a parking citation. Thank you for your cooperation. Seena Salyani Administrator, Ophthalmology Karen Aldridge Administrator, Otolaryngology

3 To: All Patients Provider: Appointment Date and Time: From: Re: USF Eye Institute and Ear, Nose and Throat Center Patient History Forms Attached Please complete and sign the attached forms and bring them with you to your scheduled appointment. **Note**If the appointment is for a minor, a parent or legal guardian must accompany the child and sign the consent to treat a minor in front of a witness at the time of the appointment. If accompanied by other than a parent, we will need to see either the court order stating that you have legal custody or you must bring a notarized letter from the parent stating that you are authorized to accompany the minor and consent to treat, or the minor will not be seen (you must bring this to every office visit and present at the time of check-in). By completing these forms and bringing them with you, you will avoid delays upon your arrival for your scheduled appointment. Thank you in advance for your cooperation. Seena Salyani Administrator, Ophthalmology Karyn Aldridge Administrator, Otolaryngology

4 PLEASE READ: The faculty and staff of the USF Departments of Otolaryngology and Ophthalmology make every effort to make your experience with us as pleasant as possible. To that end, you can assist us by familiarizing yourself with the following: You must have a valid insurance card and a picture ID with you at the time of service. Without these you will not be seen. It is your responsibility to know your insurance benefits. It is not the responsibility of this office to verify medical eligibility. It is your responsibility to be sure that the faculty of the USF Physician's Group, Departments of either Otolaryngology or Ophthalmology, are providers for your Insurance company prior to making an appointment. It is your responsibility to procure a referral or authorization for the office visit and/or procedure. You must either verify that our office has received your referral/authorization or you must bring it with you to your scheduled appointment. If you do not have a referral or an authorization, or intend to pay cash at the time of service, you will not be seen. Co-payments, co-insurance, deductibles not met, and all past due balances will be collected prior to your visit. If you fail to pay in accordance with your insurance company's contract, you will not be seen. ATTENTION FOSTER PARENTS OR LEGAL GUARDIANS. Foster Parents --you must bring a copy of the court order stating that you have legal custody or the minor will not be seen. You must bring this to every office visit and present at the time of check-in. Legal Guardians - you must bring a NOTARIZED note from the parent stating that you are authorized to accompany the minor and consent to treatment. Unless otherwise stated in note, a new note will be required for every visit, or the minor will not be seen.

5 BASELINE FORM CHIEF COMPLAINT Why have you come to see the doctor today? NAME AGE DATE PAST MEDICAL HISTORY Have you had any health problems in the past? Yes No If yes, list them noting each problem and the date. Have you had any surgery in the past? Yes No If yes, list the surgery and the date. Please list all medications you take. Please write the amount and how often you take the medicine. Are you allergic to any medications? Yes No If yes, please list the medication. Please check any of the listed Medical Problems (current or in the past) Yes No Yes No Yes No Yes No High Blood Pressure Blood Problems Kidney Disease Stroke Stomach Ulcers Heart Disease Tuberculosis Lupus Rheumatoid Arthritis Lung Disease Liver Disease Diabetes Sinus Infections Skin Disorders Thyroid Disease Cancer Other: SOCIAL HISTORY What type of work do you do? Have you ever smoked? Yes No If yes, how many packs per day? How many years? If you have stopped, when was the last time you smoked? Do you currently drink alcohol? Yes No If yes, how much? If you no longer drink alcohol please list date you stopped.

6 Do you live alone, with someone, or in a group setting such as a nursing home? FAMILY HISTORY Is there anyone in your family who has had similar health problems? Yes No If yes, what kind and who had it? Are there any diseases that run in your family (i.e. High Blood Pressure, Diabetes, Cancer)? Yes No If yes, please list the disease and who had it. REVIEW OF SYSTEMS Do you NOW have or have you RECENTLY had any of the following symptoms or problems? CONSTITUTIONAL YES NO YES NO YES NO Tiredness Easy Fatigue Muscle Soreness Night Sweats Weight Loss Pain when combing hair Fever Joint Pain Swollen Glands CARDIOVASCULAR Chest Pain Pacemaker Ankle Swelling Heart Attack Shortness of Breath when climbing stairs or with work RESPIRATORY Asthma Pain when taking a Pneumovax? Deep breath Flu Shot? Pneumonia Shortness of Breath GASTROINTESTINAL Sore Throat Diarrhea Heartburn Constipation Difficulty Swallowing Diarrhea Black Tarry Stools MUSCULOKELETAL Muscle Pain Limb Weakness Arthritis SKIN Rash Skin Lesions Jaundice NEUROLOGICAL Dizziness Weakness Decreased Concentration Numbness Tingling Headache UROLOGIC Blood in Urine Trouble starting stream Increased Frequency Kidney Infection Pain when urination ENDOCRINE Extreme thirst Sensitive to heat Sensitive to cold HEMATOLOGIC Easy Bruising Get Infections Easily Nose Bleeds Comments: PATIENT SIGNATURE I have reviewed and confirm the above information with my changes,, DATE DOCTOR SIGNATURE

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