Multiple Sclerosis Center of Nebraska
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- Jasmin Martin
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1 Multiple Sclerosis Center of Nebraska Date: Initial Visit Patient Information (Multiple Sclerosis) To be Completed Before Appointment Patient Name: DOB: Address: Social Security Number: Power of Attorney (if applicable): Do you have an Advance Directive?: Who referred you to our office?: Primary Care Physician (PCP) or Nurse Practitioner: PCP Address (City, State): Pharmacy: / Name Address (City, State) Home Phone: Daytime Phone: Cell Phone: Are you employed? Yes No If Yes, Employer: Occupation: Are you disabled?: Reason for Clinic Visit: Reason for Clinic Visit: (please check one) I have been diagnosed with MS and seek continued care Diagnosis Date: By Whom was Diagnosis Made? I have not been diagnosed with MS, but may have it I seek a second opinion about diagnosis/therapy Other, please specify: ~ 1 ~
2 Multiple Sclerosis Center of Nebraska Intake Form (continued) Date of FIRST symptom(s): What symptom(s) did you experience at that time? Duration of symptoms: (hours/days/weeks/months/years). Did you receive treatment for the symptoms? If so, what type of treatment did you receive? New symptom events (or attacks of MS) (Please list in chronological order starting with the most recent: Month/Year Symptom Events Began Symptom(s) Duration of Symptoms Was/Were Symptom(s) Treated With Steroids? Did Symptom(s) Resolve Completely? Please read through the following list carefully and circle any medications you have ever taken. Avonex (interferon beta-1a) Betaseron (interferon beta-1b) Gilenya (fingolimod) Rebif (interferon beta-1a) Copaxone (glatiramer acetate) Azasan (azathioprine) Tysabri (natalizumab) Cytoxan (cyclophosphamide) Neosar (cyclophosphamide) Rituxan (rituximab) Extavia (interferon beta-1a) Neoral (ccyclosporine) Cellcept (mycophenolate mofetil) Sandimmune (cyclosporine) Arava (leflunomide) Imuran (azathioprine) Leustatin (cladribine) Purinethol (mercaptopurine) Solumedrol (methylprednisolone) Decadron (dexamethasone) Methotrex (methotrexate) Prednisone Plasma exchange/pheresis Rheumatrex (methotrexate) Intravenous Immunoglobulin (IVIG) Novantrone (mitoxantrone) Trexall (methotrexate) Fludara (fludarabine phosphate) Alimta (premetrexed) Actimmune (interferon) Infergen (interferon) Intron A (interferon) Pegasysy (interferon) PEG-Intron (interferon) Rebetron (interferon) Roferon-A (Interferon) Humira (adalimumab) Amevive (alefacept) Campath (Alemtuzumab) Kineret (anakinra) Zenapax (daclizumab) Raptiva (Efalizumab) Enbrel (etanercept) Remicade (infliximab) Herceptin (trastuzumab) Aubagio (teriflunomide) Tecfidera (dimethyl fumarate) Ampyra (aminopyridine) Please provide details for any of the above medications you have taken: Medication Name Dates on Treatment Start-End Date(s) Reason for Stopping ~ 2 ~
3 Please list any other medications you have taken for MS symptoms: Multiple Sclerosis Center of Nebraska Intake Form (continued) Medication Name Dates on Treatment Start-End Date(s) Reason for Stopping Please provide details for your current medications (including vitamins and/or natural supplements): Medication/Supplement Name Dose and How Often Reason for Taking this Medication Medication Allergies (Please include contrast dye (CT or MRI) if applicable): I have no known drug allergies Medication: Reaction: Please list Diagnostic Tests You Have Had. Diagnostic Test Type: Where Done? Date of Most Recent Study Brain MRI Spine MRI Spinal Tap Visual Evoked Potentials Nerve Conduction Study ~ 3 ~
4 Past Surgeries: Multiple Sclerosis Center of Nebraska Intake Form (continued) Type: Year: Type: Year: Medical History: Have you ever had or been diagnosed with any of the following: Stroke/TIA Irregular Heart Rate Pneumonia Epilepsy Valve Problems: (e.g., Prolapse, Murmers) Bronchitis Seizures High Cholesterol Thyroid Problems Parkinson's Disease Fainting Ear, Nose or Throat Problems Tremor Anemia Eye Problems Migraine Easy Bruising Skin Problems Meningitis Blood Clotting Problems HIV/AIDS Concussion Transfusion Mononucleosis Dizziness Hepatitis Gout Kidney Stones Liver Disease Miscarriage Dialysis Stomach Ulcers or Bleeding Sjorgens Chronic Kidney/Bladder/ Gallbladder Problems Lupus Urinary Tract Infections Kidney Failure GERD Crohn's Disease Diabetes Irritable Bowel Syndrome Rheumatoid Arthritis Prostrate Problems Diarrhea Sarcoidosis Heart attack Asthma Psychological Problems Chest Pain Emphysema/COPD Depression Hypertension Tuberculosis Anxiety Cancer: Other: How would you describe your race: White, Non-Hispanic African American Native American White, Hispanic Asian Other: Marital Status: Single Married Divorced Widowed Number of Years of Education: Number of Children and Age(s): ~ 4 ~
5 Multiple Sclerosis Center of Nebraska Intake Form (continued) Family History: Alive Age or Age of Death Major Diseases Mother Yes No Father Yes No Siblings Yes No Yes No Nicotine Product use: Never Former Stopped (Number of years ago): Amount Used: Packs of cigarettes/ Cans / Cigars per day for years Current Amount Used: Packs of cigarettes/ Cans / Cigars per day for years Alcohol use: Never Yes Number of drinks: per day / per week / per month Recreational drug use: Never Only in the past, Stopped (Number of years ago): Types of Drugs Used: Any history of IV Drug Use: Current Types of Drugs Used: Any history of IV Drug Use: No Yes No Yes Exercise: No Yes Type: How Often: FAMILY HEALTH REVIEW: Does anyone in your family have multiple sclerosis or another autoimmune disease (e.g., Multiple Sclerosis, Lupus, Crohn's Disease,Rheumatoid Arthritis, etc.)? If so, whom? Please list any health problems that have occurred in your family and which family members are/were affected. ~ 5 ~
6 Multiple Sclerosis Center of Nebraska Intake Form (continued) Review of Systems Please place an x next to current or recently experienced symptoms: Fevers/Sweats/Chills Unexplained weight loss/gain Fatigue/Lethargy Sleep Problems Vision Change Discharge in Eye(s) Pain with eye globe movement Pain with eye globe movement Excessive dryness/tearing problems Cataract Lazy eye Bleached out color perception Gray areas or black holes in vision Sinus problems/nasal Congestion/Cough/Runny Nose Hearing loss Ear fullness or pain Ringing or buzzing in ears Sores on tongue/gums/mouth Problem with teeth Trouble swallowing Hoarseness Sore Throat Chest pain/discomfort Palpitations or irregular heart beat Shortness of breath/wheezing Cough Frequent nausea or vomiting Heartburn/Reflux Stomach Pain Dark/Tarry looking stool Bright red blood in stool Constipation Diarrhea Blood in urine Pain with urination Bladder Problems Gynecological Problems and/or sexual problems Abnormal menstruation Breast lump or discharge Erectile Problems and/or other sexual problems genital ulcers frequent urinary infections Joint pain Joint swelling or redness Tender muscles Back or neck pain Skin Cancer Rash/Skin Discoloration Injection site lumps Injection site pain/red Seizures Loss of consciousness Dizziness/light headed Dizziness/Vertigo Headaches Racing thoughts/anxiety Poor mood/depression Suicidal thoughts Easy bruising/bleeding Enlarged lymph glands/swollen Glands Swelling of Extremities Difficulty with Balance/Coordination Numbness/Weakness Abdominal Pain/Swelling/Bloating Any changes in your ability to think or understand things Please list any other symptoms you are experiencing or have recently experienced: ~ 6 ~
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1584 Wesleyan Drive FORM A Norfolk, VA 23504 Phone: (757) 455-3108 Health History immunization & Physical Form
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PATIENT REGISTRATION
PATIENT REGISTRATION Patient s Last Name: Patient s First Name: MI: Address: City, State Zip code: Patient s Date of Birth: Patient s Social Security: Best Number to contact: Secondary Number: Marital
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ICNA Relief USA Shifa Free Medical Clinic 1092 Johnnie Dodds Boulevard, Suite 108 Mount Pleasant, SC 29464 Tel: (843) 352-4580 Fax: (843) 375-9063 Last Name Street Address City, State, Zip Code Home Phone