Welcome to the UCLA Neurology Clinic!
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- Hester Riley
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1 UCLA NEUROLOGY CLINIC 300 MEDICAL PLAZA, SUITE B200 BOX LOS ANGELES, CA Welcome to the UCLA Neurology Clinic! The UCLA Westwood Neurology Clinic is a highly integrated department of neurologists with sub-specialization in the evaluation, and treatment of disorders affecting the nervous system. The Clinic offers state-of-the-art expert consultative, diagnostic and therapeutic services for a full range of neurological conditions such as Cognitive Disorders, Epilepsy, Movement Disorders, Multiple Sclerosis, Neurogenetics, Neurorehabilitation, Neuromuscular Disorders, Neuro-Oncology, Neuro- Otology, Sleep Disorders, and Stroke. Our department has earned outstanding reputation in subspecialty care of neurological disorders due to a high level of clinical expertise, academic achievement and innovative research. Our most important mission is to provide each patient with the best neurological health care available by combining our extensive experience with the latest advances in neurology. Our faculty and staff work together as a team to bring each patient the highest quality of care in a warm, friendly and professional environment. Further information about our clinics can be found online by logging to the UCLA Neurology Home Page: and navigating to the Clinical site. We look forward to seeing you here. Alon Y. Avidan, MD, MPH Medical Director, UCLA Neurology Clinic Bindu Rudramurthy Director of Clinical Operations, Neurology UCLA Neurology Clinic: 300 UCLA Medical Plaza, Suite B200 Box Los Angeles, CA Website: (CLINICAL) Phone: Fax: Medical Records: Welcome to the UCLA Neurological Services Clinic in the 300 Medical Plaza. To serve you best, we would like to tell you about our services. UCLA Form #31574 Rev. (01/10) Page 1 of 3
2 Many people have managed health care coverage from health maintenance organizations (HMOs) and preferred provider organizations (PPOs). Coverage and benefits vary widely. In most health care plans, to see physicians trained in a certain area of medicine such as neurology, your visit and any recommended tests from our doctors must be authorized by your primary care doctor's medical group and your health plan in advance. You should have obtained a written authorization from your health plan prior to making your appointment. Be sure to bring the authorization statement with you to your appointment. If you are a Medicare member, you may have different coverage or requirements. We ask that you kindly familiarize yourself with your specific insurance benefits. Often you will be asked to pay fees from $5 up to $50 (known as a co-payment) upon arrival. You may find information on whether you are required to pay a copayment by reviewing your heath plan booklet and your membership card. If you do not have a written authorization for the visit or if your health membership card, or if you do not have health insurance, the cost for the first visit ranges from $380 to $690. Payment by cash, check or credit card is expected at the end of the visit. Enclosed, please find the followings: Your appointment confirmation, Map to the UCLA Neurology Clinic Patient Questionnaire to be completed PRIOR to your appointment and to be turned in to the receptionist upon arrival to our clinic. Please plan to arrive at least 20 minutes prior to your appointment. You may be rescheduled if you are more than 20 minutes late for your new visit In order for us to serve you best, please remember to: Bring your medical insurance eligibility card Insurance claim forms (copayment and authorization documents) Pertinent medical records (Imaging, MRI, CT, EEG, EMG, sleep Studies and blood work). Names, complete addresses and telephone number of your referring physicians Completed patient questionnaire. You MUST call us at least 72 hours in advance if you need to change your appointment. If you fail to notify us of cancellation within 72 hours, you may be subjected to a $50 cancellation fee. If you have any questions or need to reschedule your appointment, please call (310) UCLA Form #31574 Rev. (01/10) Page 2 of 3
3 DIRECTIONS TO THE UCLA NEUROLOGY CLINIC AT 300 UCLA MEDICAL PLAZA: Your appointment is in 300 Medical Plaza about ½ block north of the intersection of Westwood Boulevard and Le Conte Ave. From 405 North, exit Wilshire Blvd., Westwood. From 405 South, exit Wilshire Blvd., East. From Wilshire Blvd heading East, turn left (north) on Westwood Blvd. Proceed 4 blocks and cross Le Conte Ave. Turn left at the first signal light into the Medical Plaza driveway & proceed to Visitor Parking (See Parking instructions below). Proceed to 300 Medical Plaza (Three story Building with Clock). The Neurology Clinic is located in the B 1 (Basement Level) Suite 200. PARKING Follow the one-way circular driveway. Take the ramp into underground parking on your left side. Proceed to the parking area for 200 & 300 UCLA Medical Plaza. The parking fee is $11 per car entry. Handicapped parking is available at the underground entrance of 300 Medical Plaza. There is a $3.00 parking charge for visitors displaying valid handicapped plates or placards. PATIENT DROP-OFF AREAS LOCATIONS OF CLINIC A drop-off area is located in front of the 300 Medical Plaza (Building with clock) on the circular driveway at the street level. Take the elevator to level B 1. In the underground parking structure, you will enter on level B 1. Follow the sign to Neurological Services, Suite B200. UCLA Form #31574 Rev. (01/10) Page 3 of 3
4 PATIENT INFORMATION Last, First, Middle Name Today s Date Age Birth Date Sex: Native Language: Male / Female Referring Physician s Full Name Telephone #: Physician s Address Are you: Right-handed Left-handed Ambidextrous Why do you need to see a Neurology specialist? Past Medical History Date Diagnosed Hospitalizations, Operations and dates Injuries and dates. Include any episodes of loss of consciousness. Blood Transfusions and dates Drug Allergies and reactions: UCLA Form #31574 Rev. (01/10) Page 1 of 4
5 Medications (current and/or recent) Name Dosage How often? (*Attached typed sheet/write on back if necessary) Dietary Supplements/Vitamins: Name Dose & Frequency Social History Any use of tobacco (type and for how long)? Any use of alcohol (type and for how long)? Any use of recreational drugs (type and for how long)? Any exposure to toxins/poisonous substances at work or with hobbies? What type of work do you do? Education: Grade School High School College Post-Graduate Voc. Training Marital Status: Single Married Divorced Separated Widowed Birthplace: UCLA Form #31574 Rev. (01/10) Page 2 of 4
6 FAMILY HISTORY Mother: Living or deceased? Health Problems: Father: Living or deceased? Health Problems: Age: Age: Brothers/Sisters: List from the oldest to youngest. 1. Brother or sister? Living or deceased? Age: 2. Brother or sister? Living or deceased? Age: 3. Brother or sister? Living or deceased? Age: 4. Brother or sister? Living or deceased? Age: Children: List from oldest to youngest. 1. Daughter or son? Living or deceased? Age: 2. Daughter or son? Living or deceased? Age: 3. Daughter or son? Living or deceased? Age: Have any of your family or relative had the following health conditions? If yes, whom? Heart disease High blood pressure High cholesterol Loss of memory Epilepsy/seizures Depression Mental disease Muscle weakness Other: Stroke Fainting Diabetes Cancer Multiple sclerosis Polio Limping Thyroid disease THANK YOU VERY MUCH FOR COMPLETING EHIS QUESTIONNAIRE. BE SURE TO BRING IT TO YOUR DOCTOR S APPOINTMENT UCLA Form #31574 Rev. (01/10) Page 3 of 4
7 REVIEW SYSTEMS Please place a checkmark if you currently have any of the following symptoms. (Disregard the bold headings in quotes on the left. They are for administrative purposes only). 1. "constitutional fever weight loss fatigue 2. eyes problem blurred vision double vision loss of vision eye pain eye redness eye dryness 3. ear/nose/throat trouble hearing ringing in ear(s) dizziness (vertigo) loss of balance ear pain ear discharge hoarseness trouble swallowing slurred speech 4 cardiovascular chest pain Irregular heart beat fast heart beat limb swelling limb pain on walking fainting 5. respiratory trouble breathing chronic cough coughing blood 6. gastrointestinal indigestion heart burn abdominal pain nausea vomiting regurgitation diarrhea constipation bloody stools 7. genitourinary incontinence pain on urination blood in urine 8. musculoskeletal muscle pain muscle cramp muscle twitches loss of muscle bulk neck pain back pain joint pain joint stiffness joint swelling 9. skin & breast numbness tingling discoloration 10. neurologic headache face pain face numbness weakness tremors clumsiness blackouts trouble with memory trouble concentrating 11. psychiatric hallucinations feeling depressed trouble sleeping suicidal thoughts Inappropriate crying inappropriate laughing 12. hematologic/lymphatic abnormal bleeding nose bleeds lumps or swellings 13. allergic/immunologic skin rash Joint pain dry eyes & or dry mouth 14. endocrine excessive thirst heat or cold intolerance excessive urination Person completing questionnaire Relationship to patient For office use: This questionnaire may be completed by the patient, relative or ancillary staff provided that it is signed and dated by the treating physician. (Reference may later be made to this information by a signed and dated statement by the treating physician, designating location of the information, date obtained and any subsequent charges.) Physician s signature: Date: Time: UCLA Form #31574 Rev. (01/10) Page 4 of 4
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