Burlington Neurology & Sleep Clinic, P.L.C.
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1 Burlington Neurology & Sleep Clinic, P.L.C. New Patient Intake Form Dict Done: Date: Name: Patient ID: DOB: _ Age: Height: Weight: Blood pressure: Pulse: Handedness: Right Left _ Ambidextrous Primary Care Physician: Date symptoms began: _ Main reason for your visit: Describe briefly your present symptoms (problems): Previous treatment for this problem (include physical therapy, surgery and medications) Date of most recent blood test: Recent X-rays/MRI/CT (circle): When? Where? Where? Please list the names of other doctors you have seen for this problem: Name of Pharmacy: MEDICATIONS: Name of Drug Dose Directions Drug Allergies: Drug What reaction? Page 1
2 PAST MEDICAL HISTORY: Do you have or have you had these medical conditions: Fainting Tremor Heart disease Autoimmune disease Atrial fibrillation Osteoarthritis CHF Depression Hypertension Anxiety disorder High Cholesterol Migraine/headache Other: Diabetes Epilepsy Thyroid Dysfunction Stroke syndrome COPD Polyneuropathy Asthma Dementia Cancer Motion sickness GI Disorder Restless Legs Kidney disorder Obstructive sleep apnea Previous Operations: Carotid artery surgery Hysterectomy Heart Valve replacement Appendectomy Carpal tunnel release Back Surgery Knee replacement Brain surgery Hip Replacement Tonsillectomy Gall bladder removal Pacemaker Other surgery: Patient Number Page 2
3 SOCIAL HISTORY: Marital status: (circle) Never married Married Divorced Separated Widowed Do you smoke? (circle) yes no How much? cigarettes/ packs a day(circle one) Given counsel to abstain? (circle) yes no. How much alcohol do you drink? per day per week per month Illicit drug use (circle): yes no. If yes, what and how often: Occupation: Do you live alone? (circle) yes no. If no, with who and what is their relationship to you? : FAMILY HISTORY: Mother 1 Father - 2 Brother - 3 Sister 4 Please note with the above numbers if a member of your family has been diagnosed with: Coronary artery disease Migraine/headache Congestive heart failure Epilepsy Hypertension Stroke Syndrome High cholesterol Dementia Diabetes Parkinson s Disease COPD Restless leg syndrome Cancer Obstructive sleep apnea Depression Tremor Patient Number Page 3
4 REVIEW OF SYSTEMS: (CURRENT COMPLAINTS) Systemic Symptoms Weight Change Chills Fever Night Sweats Other constitutional Pulmonary Symptoms Shortness of breath Cough Coughing up blood Night sweats Wheezing Other Pulmonary symptoms HEENT symptoms Headache Eyesight problems Nosebleeds Other head-related symptoms Cardiovascular symptoms Chest pain or discomfort Fast heart rate Palpitations Other cardiovascular symptoms Gastrointestinal symptoms Neck Symptoms Neck pain Neck stiffness Lump or swelling in the neck other neck symptoms Difficulty swallowing Heartburn Nausea Vomiting Abdominal pain Diarrhea Gastrointestinal symptoms Genitourinary Symptoms Blood in urine Difficulty/pain with urination Increased urinary frequency Skin symptoms Itching Skin lesions Rashes Other skin symptoms Hematological symptoms Easy bleeding Easy bruising Psychological symptoms Sleep disturbances Depression Anxiety Endocrine symptoms Excessive sweating Excessive thirst Other endocrine symptoms
5 Patient Number Page 4 SLEEPINESS: Epworth Sleepiness Scale How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? Use the following scale to choose the most appropriate answer for each of the following. A score of > 10 puts you at risk of a sleeping disorder. 0 = would NEVER doze 1 = SLIGHT chance of dozing 2 = MODERATE chance of dozing 3 = HIGH chance of dozing Situations: Sitting and reading Watching TV Sitting inactive in a public place (theater,meeting) As a passenger in a car for an hour without a break Lying down in the afternoon when able Sitting and talking to someone Sitting quietly after a lunch without alcohol In a car while stopped for a few minutes in traffic Total STOP scoring model Do you snore loudly (louder than talking or loud enough to be heard through closed doors? Do you often feel tired, fatigued or sleepy during the daytime? Has anyone Observed you stop breathing during your sleep? Do you have or are you being treated for high blood pressure? High risk of OSA: answering yes to 2 or more items Low risk of OSA: answering yes to less than 1 item Total yes answers
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Associates in Pediatric & Adult Urology, PA A division of Garden State Urology 282 Route 46 PO Box 1160 Denville, NJ 07834
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Name: Date of Birth: Age: Male / Female (circle one) Pregnant Yes / No (circle one) Reason you are here:
Eastside Medical Group: DATE: Name: Date of Birth: _Age: Male / Female (circle one) Pregnant Yes / No (circle one) Reason you are here: SOCIAL HISTORY Marital Status: Single Married Partner Divorced Widow/Widower
www.njspinecenter.com
INSTRUCTION: When all forms are complete, save the document to your computer, open your email and forward it as an attachment to appointments@njspinecenter.com or fax it to 973-635-3137. Future changes
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PATIENT REGISTRATION FORM
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Patient Checklist. Expect to pay your co-pays and non-covered services on the day of service.
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Mid-State Neurosurgery, P.C Back & Neck Pain Center
Mid-State Neurosurgery, P.C Back & Neck Pain Center Patient Name: Date of Birth: Heart HISTORY Attack OF PRESENT ILLNESS Stroke Seasonal Allergies Diabetes What is the reason for today s visit? When did
Surgical weight loss. Life-changing results.
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Calais Dermatology Associates
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PODIATRIC ASSOCIATES OF NW OHIO, INC. DATE PATIENT HISTORY PATIENT S LAST NAME FIRST NAME MIDDLE SOCIAL SECURITY NUMBER ADDRESS STREET APT. NO. CITY STATE ZIP DATE OF BIRTH AGE SEX MARITAL STATUS HOME/CELL