Multiple Sclerosis Center of Nebraska



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

SOUTH TAMPA MULTIPLE SCLEROSIS CENTER

SOUTH TAMPA MULTIPLE SCLEROSIS CENTER PATIENT/ CARE GIVER QUESTIONNAIRE

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

NEW PATIENT HISTORY QUESTIONNAIRE. Physician Initials Date PATIENT INFORMATION

Information About Medicines for Multiple Sclerosis

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

Pulmonary Associates of Richmond

Information about medicines for multiple sclerosis

MEDICAL HISTORY AND SCREENING FORM

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

Patient Information Form Pain Management Center at Phoebe

PATIENT INFORMATION INSURANCE INFORMATION

PATIENT HEALTH QUESTIONNAIRE: Urology

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

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

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

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

Progress in MS: Current and Emerging Therapies

Surgery Health Survey

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

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

Patient Intake Form. Patient Information. How did you find out about our office?

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

PATIENT / VISIT INFORMATION PATIENT INFORMATION

WORKERS COMPENSATION INFORMATION

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

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

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

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

ORTHOPAEDIC SPINE PAIN QUESTIONNAIRE

Motor Vehicle Accident - New Patient

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

Personal Injury Questionnaire

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

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

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

MEDICAL HISTORY INFORMATION

Workman s Compensation

Board Certified Endocrinology, Diabetes & Metabolism Palm Harbor, FL Phone (727) FAX (727)

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

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

New Patient Intake Form

MS Disease Management Program

Rehabilitation Medicine Clinic. New Patient Questionnaire

6. Do you have an Advance Directive or Living Will? Yes No These are written statements about how you want to be treated if you get very sick.

PATIENT REGISTRATION

General Internal Medicine Clinic New Patient Questionnaire

PATIENT HEALTH QUESTIONNAIRE Radiation Oncology (Patient Label)

ALBANY PLASTIC SURGEONS, PLLC 4 Executive Park Drive Albany NY (518) PATIENT INFORMATION FORM

NEW PATIENT INFORMATION FORM

1960 Ogden St. Suite 120, Denver, CO 80218,

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

MODULE 1 SWAN NEW PATIENT INFORMATION FORM Universal New Patient Demographic Form

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

New Patient Registration Information

Plano Heart Center, P.A.

PATIENT HISTORY FORM

New Patient Evaluation

Women s Continence and Pelvic Health Center

NEW YORK SPINE & PAIN PHYSICIANS NEW PATIENT QUESTIONNAIRE

PELED PLASTIC SURGERY HEADACHE HISTORY FORM

Thank you for making an appointment with our office. We look forward to serving your visual needs.

Review of Systems. Eye/Ear/Nose/Throat. hard to empty bladder. palpitations/irregular heartbeat. persistent cough, wheezing. feelings of depression

PATIENT DEMOGRAPHICS & INSURANCE INFORMATION

Disease Modifying Therapies for MS

New England Pain Management Consultants At New England Baptist Hospital

MEDICATION GUIDE. ACTEMRA (AC-TEM-RA) (tocilizumab) Solution for Intravenous Infusion

Health Information Form for Adults

IMS Allergy & Immunology New Patient Registration Sheet. Personal Information

WELCOME PATIENT CONDITION

Immune Modulating Drugs Prior Authorization Request Form

How To Write A Recipe Card

Southwestern Foot & Ankle Associates, P.C Parkwood Blvd, Suite 602 Frisco, TX Phone: Fax: Dr. Thomas H.

PLEASE PRINT LEGIBLY

***************PATIENT INFORMATION****************

Health Information Form for Adults

PATIENT DEMOGRAPHICS:

Arthritis, Rheumatic & Back Disease Associates, P.A. Greentree Osteoporosis Center

Which injectable medication should I take for relapsing-remitting multiple sclerosis?

SPINE PATIENT HISTORY FORM

FEMALE DRIVER S LICENSE NUMBER STATE ISSUED PLACE OF BIRTH CITY STATE CITY STATE ZIP CITY STATE ZIP COUNTY USA

Integrated Medical Services (IMS) New Patient Registration Sheet

Emory Eye Center New Patient Questionnaire

1584 Wesleyan Drive FORM A Norfolk, VA Phone: (757) Health History immunization & Physical Form

Patient Medical History Form

PATIENT REGISTRATION

OrthoVirginia Registration Information 2016

PATIENT INFORMATION INSURANCE PHONE NUMBERS ACCIDENT INFORMATION GENERAL INFORMATION. Sex: M F Age Birthdate. Date. Name. Relationship to Patient

CLINIC APPLICATION. Client Information

Transcription:

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: Email: 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 ~

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 ~

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 ~

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 ~

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 ~

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 ~

2026 © DocPlayer.net Privacy Policy | Terms of Service | Feedback  | Do Not Sell My Personal Information