INITIAL VISIT CHECKLIST. Bring COMPLETED new patient forms. Verify medication list is up-to-date.
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1 Baylor Neuroscience 9101 N. Central Expressway Suite 190 Dallas, Texas INITIAL VISIT CHECKLIST Bring COMPLETED new patient forms. Verify medication list is up-to-date. If this evaluation is to address memory issues, we request you bring a family member or primary caregiver with you. If you have undergone formal neuropsychological or memory testing in the past, please bring a copy of the report with you. If you do not have a copy, kindly contact our offi ce prior to your appointment. We will be happy to request the report on your behalf. Wear glasses and hearing aids if you use them. Bring your insurance cards and picture ID. Please note Baylor accepts traditional Medicare, but DOES NOT accept Medicare Advantage plans. Please take the time to look at your insurance card. Traditional Medicare cards have a red and blue stripe running across the top of the card. These stripes typically frame the words Medicare Health Insurance or Health Insurance. If your card does not have this appearance, call our offi ce immediately so we assist you in determining your plan. Pharmacy Information. Our offi ce submits prescriptions electronically. Please provide both your local and mail order pharmacy information below, even if you prefer one over the other. If your local pharmacy is a chain (ex. CVS, Walgreens, Costco) it is most helpful to have the store number vs. the phone number. The store number can be found next to the pharmacy name on your prescription bottle (ex. CVS #1401). If your local pharmacy is not part of a large chain, kindly provide its street address and phone number. Preferred Local Pharmacy: Mail Order Pharmacy (if applicable): (05/11) INITIAL VISIT CHECKLIST
2 MEMORY CENTER NEW PATIENT FORM Date of Appointment: Date of Birth: Patient Name: Primary Concern(s): Referring Physician: Primary Care Physician: Phone/Fax: Phone/Fax: PAST MEDICAL HISTORY Heart/Vascular Disease/Stroke: Hypertension (High Blood Pressure) Hyperlipidemia (High Cholesterol) Coronary Artery Disease If yes, do you have history of: Myocardial Infarction (Heart Attack) Coronary artery bypass surgery Angioplasty / Stents Pacemaker Congestive Heart Failure Stroke / CVA TIA (Transient ischemic attack) Subdural hematoma Lung Disease: COPD Asthma On Oxygen Gastrointestinal Disease: History of gastrointestinal bleed Chronic diarrhea Crohn s disease Chronic Constipation Irritable bowel syndrome Ischemic Colitis Endocrine: Diabetes Hypothyroidism Hyperthyroidism Neurological: Parkinson s disease Seizure disorder Multiple Sclerosis Past head injury Tremor Migraines Neuropathy Kidney and Liver: Hepatitis Cirrhosis Ear / Nose / Eye: Hearing loss Seasonal allergies Macular degeneration Glaucoma Cataract(s) (08/11) MEMORY CENTER NEW PATIENT FORM Page 1 of 2
3 Other: Cancer (list types) Chronic pain (list areas) Arthritis If yes, Rheumatoid Osteoarthritis Other pertinent Health History: Past Surgeries: Past Testing: CT / MRI of the BRAIN. Please list approximate date of most recent imaging as well as where completed (Imaging center or hospital name) Neuropsychological Testing. This is a constellation of verbal and written tests to assess memory and other brain functions. It typically takes several hours to complete. If yes, who performed the testing and what year was it done? Social History: Marital: Single Divorced Married Separated Widowed Number of biological / adopted children: Highest level of education completed: (ex. 10 th grade, high school graduate, some college, Master, etc.) Full time Part Time Retired Disabled Former or current occupation: History of drug or alcohol issues? Living situation: Home or apartment Senior community / Independent Living Assisted living Memory care Nursing home Name of community Name of community Name of community Name of nursing home (08/11) MEMORY CENTER NEW PATIENT FORM Page 2 of 2
4 MEDICATIONS If your medications are administered by staff at your residential community, please attach the current Medication Administration Record (MAR). Your nurse can print a copy for you. You DO NOT have to complete the remainder of form. Allergies to Medication: Medications You Take on Daily Basis including Vitamins & Supplements: [Suggested format: metoprolol 25 mg 1/2 tab in AM and 1 tab at bedtime] As Needed (PRN) Medications: List drugs and doses, even if do not take on regular basis. Sleeping Medications: Pain Medications: Anxiety Medications: Other: Do you take? Aspirin. If not listed above, what is your dose? Benadryl (diphenhydramine) products, including Tylenol PM or Advil PM (08/11) MEDICATIONS
5 REVIEW OF SYSTEMS Check yes only if you have experienced symptom RECENTLY General Loss of Appetite Loss of Weight Fever Fatigue Eye/Ear/Nose/Throat Vision Loss Hearing Loss Diffi culty Swallowing Sinus or Allergy Symptoms Cardiovascular Chest pain Palpitations / Irregular Heartbeat Shortness of Breath Respiratory Cough Wheezing Bronchitis Pneumonia Gastrointestinal Refl ux Abdominal Pain Constipation Urinary Urinary Frequency Incontinence Urinary Tract Infection Sleep Insomnia Daytime Sedation / Frequent Naps Neurological Headache Numbness / Pain in Feet Weakness Falls Syncope (Passing Out) Trouble Walking Tremor Change in Handwriting Psychiatric Depression Apathy / Disinterest Anxiety Irritability Suspiciousness / Paranoia Hallucinations Diarrhea Nausea / Vomiting (07/11) REVIEW OF SYSTEMS
6 BEHAVIOR CHECKLIST Current Problems NONE MILD MODERATE SEVERE Depressed Mood Disturbed Sleep Appetite Changes Significant Change in Weight Poor Concentration Hopelessness Suicidal Thoughts Tense/Anxious Fearfulness/Panic Obsessive Thoughts Compulsive Behavior Memory Loss Confusion/Disorientation Apathy/Loss of Interest Irritability/Easily Frustrated Suspiciousness/Paranoia Hostility/Anger Combativeness/Aggression Hallucinations Problems Maintaining Hygiene Word Finding or Language Problems Inappropriate Behavior/Loss of Social Graces (07/11) BEHAVIOR CHECKLIST
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SLEEP DISORDERS CENTER SLEEP CLINIC PATIENT QUESTIONNAIRE. Please bring this completed questionnaire with you to your sleep clinic appointment.
SLEEP DISORDERS CENTER Please bring this completed questionnaire with you to your sleep clinic appointment. Patient s Name: Date: Referring Physician: Clinic Location: 1. Why are you being seen in the
NORTHEAST SPINE & SPORTS MEDICINE PATIENT INTAKE MAILING ADDRESS: CITY: STATE: ZIP CODE: HOME PHONE#: CELL#: WORK PHONE#: S / M / D / W
NORTHEAST SPINE & SPORTS MEDICINE PATIENT NAME: PATIENT INTAKE SOCIAL SECURITY#: SEX M/F: DATE OF BIRTH: AGE: MAILING ADDRESS: CITY: STATE: ZIP CODE: EMAIL ADDRESS: HOME PHONE#: CELL#: WORK PHONE#: EMPLOYER:
MEDICAL HISTORY INFORMATION
MEDICAL HISTORY INFORMATION Name: Birthdate: Age: Address: Home Telephone: Cell Telephone: Work Telephone: Social Security Number: Marital Status: Single Married Divorced Widowed Spouse s Name: Birthdate:
Western Center Eye Care 2720 Western Center Blvd Ste 316 Fort Worth, TX 76131
Today s Date Western Center Eye Care WELCOME TO OUR OFFICE Patient s Name (First, Middle, Last): Address: City: State: Zip Code: Email: Main Contact #: Alternate#: Date of Birth: / / Sex: Male Female Primary
Patient Registration Form
PATIENT INFORMATION Patient Registration Form (Please Print) Dr. Miss Mr. Mrs. Ms. Sir Jr. Sr. Patient s Name (Last) (First) (MI) Previous Name Mailing Address City, State, ZIP (+4) Physical Address City,
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
Limited Pay Policy (L-222B) - Underwriting Guidelines
Limited Pay Policy (L-222B) - Underwriting Guidelines 1 Addiction/Abuser Drug - Past or Present Presently Recovered - AA for last 2 years 2 Aids 3 Alcoholic Presently Recovered - AA for last 2 years 4
Surgery Health Survey
Surgery Health Survey Name: Social Security Number: Date of Birth: Please tell us which physician(s) we should contact regarding your visit: REFERRING PHYSICIAN Name: Address: PRIMARY CARE PHSYICIAN Name:
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM PATIENT INFORMATION Patient s Name: First Middle Initial Last DOB: / / Address: City: State: Zip: Primary Phone: - - Secondary Phone: - - Email: (for patient portal purposes only)
Shelby Foot & Ankle 1. PATIENT INFORMATION 2. INSURANCE. 50505 Schoenherr Road, Suite 230 Shelby Township, MI 48315 (586) 580-3728 www.shelbyfoot.
: 1. PATIENT INFORMATION 2. INSURANCE SS/H/C/Patient ID#: Patient Last Name: Who is responsible for this account? Relationship to Patient: Insurance Co.: Patient First Name: Middle Int: Group #: Address:
ORTHOPAEDIC SPINE PAIN QUESTIONNAIRE
ORTHOPAEDIC SPINE PAIN QUESTIONNAIRE NAME: DATE: ADDRESS: AGE: TELEPHONE#: RELIGION: OCCUPATION: REFERRED BY WHOM: NEAREST FRIEND/RELATIVE: TELEPHONE#: ADDRESS: PLEASE EXPLAIN WHY YOU HAVE COME TO SEE
Patient Medical History
Cardiovascular Abnormal Electrocardiogram Aortic Stenosis Atrial fibrillation Cardiac arrest Chest pain Congestive heart failure Heart valve replacement Hypertension Murmur Heart attack Palpitations Peripheral
Made to Move Physical Therapy, Inc. 615 N Nash St., Ste # 306 El Segundo, CA 90245 310.535.0008
Name Last First MI Date Current/Permanent address City State Zip Phone H W Cell Email Address: Marital Status Single Married Other Date of Birth: Age: Gender Male Female Spouses DOB: Employer Occupation