Burlington Neurology & Sleep Clinic, P.L.C.

Similar documents
Dallas Neurosurgical and Spine Associates, P.A Patient Health History

PATIENT HISTORY FORM

NEUROSURGERY SERVICES AT APD LOCATED AT UPPER VALLEY MEDICAL GROUP 106 Hanover Street, Lebanon, NH Phone: Fax:

Denver Spine Surgeons David Wong, MD, Sanjay Jatana, MD, Gary Ghiselli, MD

Sleep Disorders Center St. Michael s Dr fax Santa Fe, New Mexico QUESTIONNAIRE NAME: DOB: REFERRING PHYSICIAN:

SLEEP DISORDER ADULT QUESTIONNAIRE

NEW PATIENT CLINICAL INFORMATION FORM. Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute

Sleep History Questionnaire

North Carolina Orthopaedic Clinic Patient Registration Form

Hello, Please note: The following information will be needed at your appointment:

Borland-Groover Clinic PATIENT GENERATED MEDICAL HISTORY Name: DOB: Primary Care Physician: Pharmacy: Pharmacy Phone #:

Pulmonary Associates of Richmond

Emory Eye Center New Patient Questionnaire

NEW PATIENT HISTORY QUESTIONNAIRE. Physician Initials Date PATIENT INFORMATION

NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)

Why are you being seen at Frontier Diagnostic Sleep Center?

St. Luke s MS Center New Patient Questionnaire. Name: Date: Birth date: Right or Left handed? Who is your Primary Doctor?

Allergies to Medications: Yes ( ) No ( ) if yes, explain: Allergies to environmental agents: Yes ( ) No ( ) if yes, explain:

New Patient Intake Form

General Internal Medicine Clinic New Patient Questionnaire

VEIN CLINIC OF NORTH CAROLINA 3318 HEALY DR. WINSTON SALEM, NC PH FAX Scott W. Baker, MD. Patient Instructions

Please review, complete, and return all paperwork included in this packet. If you have any questions or concerns please feel free to contact us at

Southwest General Surgical Associates General & Vascular Surgery 8230 Walnut Hill Lane Suite 408 Dallas, TX Phone-214) Fax-214)

JAMES PETROS, M.D., INC. PHONE: (408) FAX: (408)

SLEEP DISORDERS CENTER SLEEP CLINIC PATIENT QUESTIONNAIRE. Please bring this completed questionnaire with you to your sleep clinic appointment.

PATIENT HEALTH QUESTIONNAIRE Radiation Oncology (Patient Label)

NEW PATIENT HISTORY Mark L. Prasarn, M.D.

PATIENT SELF-ASSESSMENT FORM

New Patient Evaluation

PELED PLASTIC SURGERY HEADACHE HISTORY FORM

DEMOGRAPHIC FORM PATIENT INFORMATION. Mailing Address: City & State: ZIP Code: Pharmacy: City: Cross Roads: INSURANCE INFORMATION

(Please fill this out to the best of your ability) Baker Eye Institute Conway, Arkansas NAME: Today s Date:

NORTHEAST SPINE & SPORTS MEDICINE PATIENT INTAKE MAILING ADDRESS: CITY: STATE: ZIP CODE: HOME PHONE#: CELL#: WORK PHONE#: S / M / D / W

Interventional Spine Pain Consultants, P.A. Initial Consultation Information

Full name DOB Age Address Phone numbers (H) (W) (C) Emergency contact Phone

AUBURN DERMATOLOGY PATIENT DEMOGRAPHIC (Please print legibly)

Patient Sleep Questionnaire

MOTOR VEHICLE ACCIDENT QUESTIONNAIRE

PATIENT DEMOGRAPHICS & INSURANCE INFORMATION

Pacific Sleep Program

LOW T NATION TESTOSTERONE INTAKE FORM NAME: DATE: ADDRESS: CITY: STATE: ZIP: CELL #: HOME #: SOC SECURITY #: DATE OF BIRTH:

NEW PATIENT CONSULTATION FORM. Social Security Number - - Date of Birth Age. Home Address. Home phone Cell phone. Work phone address

PATIENT REGISTRATION

POINCIANA INTERNAL MEDICINE PA. Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address:

Associated Ear, Nose & Throat Specialists, LLC. OCCUPATION: Employer: Work Phone: PHYSICIAN REQUESTING CONSULTATION: TOWN: PHONE:

Name,, Last First MI DOB Age Current Occupation. Home Phone Work phone Cell Phone

Full name: Male Female

PLEASE PRINT LEGIBLY

Texas Sinus Center PATIENT REGISTRATION. Name Birth date Soc Sec# Address City/State Zip

OMNI DERMATOLOGY, INC. NEW PATIENT INFORMATION RECORD

Duke Medicine Division of Pulmonary, Allergy & Critical Care Medicine New Patient History Evaluation. Today s Date:

Women s Continence and Pelvic Health Center

San Luis Dermatology & Laser Clinic, Inc.

Name (First): (MI) (Last) Date: Address: City: State: Zip: Home Phone: Cell Phone: Driver s License #: Driver s License State: Occupation:

Cervical Spine. New Patient Form

Plano Heart Center, P.A.

PATIENT INFORMATION / / OTHER CONTACT NUMERS: (CIRCLE ONE) CELL, HOME OR OTHER. ENTER NUMBER BELOW. ( ) EMPLOYER ( )

Notice of Privacy Practices

Princeton and Rutgers Neurology, P.A. A Center Of Excellence

Patient Information. Today s date: Your Name: Social Security Number: Date of Birth: Age: Height: Weight: lbs. Street Address: City/State/Zip:

REGISTRATION FORM PATIENT NAME: ADDRESS (STREET, CITY, STATE, ZIP): HOME PHONE: WORK PHONE: CELL PHONE: DATE OF BIRTH: / / AGE: SEX:

The NeuroCenter Swedish Covenant Medical Group 6225 W. Touhy Ave, Chicago, Il Tel: Fax:

Rheumatology Associates of North Jersey New Data Sheet

LIST ALL MEDICATIONS (BOTH PRESCRIBED AND OVER THE COUNTER) AND SUPPLEMENTS

MEDICAL HISTORY AND SCREENING FORM

Application For Admission To The Non-Surgical Spinal Decompression Program At The Spinal Decompression Center of Long Beach

PLEASE COMPLETE PRIOR TO VISIT***Place your name at the bottom of each sheet

NEW PATIENT INFORMATION FORM

PATIENT REGISTRATION FORM

Roswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico (575) Fax: (575)

CONSULTANTS IN PAIN MEDICINE, INC. TELEPHONE (757) FAX (757) INTERNET **MEDICATION GUIDELINES PRIOR TO PROCEDURES

New Patient Questionnaire

WORKERS COMPENSATION INFORMATION

Name Today's Date Sex. Street Address City State Zip Code. Home # Work # Cell # Would you like to receive text confirmations:

NEW YORK SPINE & PAIN PHYSICIANS NEW PATIENT QUESTIONNAIRE

PATIENT INFORMATION INSURANCE INFORMATION

PREMIER PAIN CARE PA Carlos J Garcia MD 2435 W. Oak Street # 103 Denton, TX Phone Fax PATIENT REGISTRATION

Shelby Foot & Ankle 1. PATIENT INFORMATION 2. INSURANCE Schoenherr Road, Suite 230 Shelby Township, MI (586)

7. X-Rays provided in our office will be billed as an outpatient service of Florida Hospital Flagler. Statement of Policies

elf-awareness Toolkit

ORTHOSPORTS ASSOCIATES

PATIENT / VISIT INFORMATION PATIENT INFORMATION

SPINE PATIENT HISTORY FORM

Interventional Spine Care New Patient History and Intake Form

building. 2. Enter Turn the on 5305 and begin Building testing and take the elevator/stairs to the third floor, turn right and go into

Patient Registration Form Please print clearly and complete all items. Patient First Name. Street Address. City State Zip

New England Pain Management Consultants At New England Baptist Hospital

CAYUGA CENTER FOR HEALTHY LIVING Geoffrey E. Moore, MD FASCSM Shannan Simkin, NP Lisa Proctor, NP ISLAND HEALTH & FITNESS COMPLEX ITHACA, NY 14850

Workman s Compensation

Surgery Health Survey

Associates in Pediatric & Adult Urology, PA A division of Garden State Urology 282 Route 46 PO Box 1160 Denville, NJ 07834

Name: Date of Birth: Age: Male / Female (circle one) Pregnant Yes / No (circle one) Reason you are here:


SLEEP AND PARKINSON S DISEASE

PATIENT REGISTRATION FORM

Patient Checklist. Expect to pay your co-pays and non-covered services on the day of service.

Mid-State Neurosurgery, P.C Back & Neck Pain Center

Surgical weight loss. Life-changing results.

Calais Dermatology Associates

PODIATRIC ASSOCIATES OF NW OHIO, INC. PATIENT HISTORY INSURANCE INFORMATION

Transcription:

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

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

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 1 2 3 4 Migraine/headache 1 2 3 4 Congestive heart failure 1 2 3 4 Epilepsy 1 2 3 4 Hypertension 1 2 3 4 Stroke Syndrome 1 2 3 4 High cholesterol 1 2 3 4 Dementia 1 2 3 4 Diabetes 1 2 3 4 Parkinson s Disease 1 2 3 4 COPD 1 2 3 4 Restless leg syndrome 1 2 3 4 Cancer 1 2 3 4 Obstructive sleep apnea 1 2 3 4 Depression 1 2 3 4 Tremor 1 2 3 4 Patient Number Page 3

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

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

2024 © DocPlayer.net Privacy Policy | Terms of Service | Feedback  | Do Not Sell My Personal Information