Patient’s Name: __________________________________________________________ Referring Doctor: _______________________________________
Age: _____________
Right or Left handed
Race: __________________________
Gender: Male or Female
Pharmacy: ___________________________________________
Location:________________________________________________________
Medication Allergies
Name of Medication
Reaction
_______________________________________
_________________________________
_______________________________________
_________________________________
Current Medications
Name
Dose
Frequency (i.e. once daily)
_________________________________
_______________
_______________________________
_________________________________
_______________
_______________________________
_________________________________
_______________
_______________________________
_________________________________
_______________
_______________________________
_________________________________
_______________
_______________________________
_________________________________
_______________
_______________________________
Patient History
Major Illnesses: ______________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
Surgeries: _____________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
Other:__________________________________________________________________________________________________________________________________
Family History
Is your mother living? _________________ If NO, died at what age? ___________________ From:____________________________________
Noteworthy medical problems: __________________________________________________________________________________________________
Is your father living? __________________ If NO, died at what age? ____________________ From:____________________________________
Noteworthy medical problems: __________________________________________________________________________________________________
Social History:
Marital Status: Married
Divorced
Widowed
Occupation: __________________________________________________
or
Tobacco Usage:
Cigarette
Pipe
Cigar
Chew
Alcohol Consumption: Beer
Wine
Hard Liquor
Separated
Single
Retired
Amount PerDay:_____________________________
Amount Per Week: __________________________
Review of Systems:
Please CIRCLE all that apply
Constitutional: anorexia, chills, diaphoresis, fatigue, fever, insomnia, night sweats, weakness, weight gain/obesity and
weight loss.
Eyes: blindness, double vision, eye discharge, eye pain, macular degeneration, photophobia, vision change and visual
disturbance.
Ears/Nose/Throat/Neck: dizziness, dysphagia, epistaxis, facial pain, headache, hearing loss, hoarseness, jaw pain,
migraines, nasal discharge, neck pain, oral pain, sinusitis, sleep apnea-obstruction, sleep disordered breathing, snoring,
sore throat, tinnitus, vertigo, vocal cord paralysis and voice change.
Cardiovascular: swelling of the legs, arrhythmia, chest pain/pressure, claudication, dyspnea, dyspnea on exertion,
edema, fatigue, hypertension, lightheadness, near-syncope/dizziness, pain in calf with walking, palpitations, reduced
exercise intolerance, syncope and tachycardia.
Respiratory: asthma, cough, daytime hypersomnolence, dyspnea, shortness of breath, snoring, and wheezing.
Gastrointestinal: abdominal pain, constipation, diarrhea, gastroesophageal reflux, nausea and vomiting.
Genitourinary/Nephrology: dysuria, nocturia, urinary urgency, urinary frequency and urinary incontinence.
Musculoskeletal: arthritis, back pain, gout, joint swelling, muscle weakness, myalgia’s, neck pain, sciatica and stiffness.
Dermatologic: arthropod bite, changing moles, growths, itching, rash, scar, skin cancer and skin lesion.
Neurologic: alteration of consciousness, aphasia, ataxia, balance, dizziness, dyskinesia or tremor, excessive thirst or
hunger, gait abnormality, headache, hearing loss, memory loss, mental status change, migraines, neck pain, numbness,
back pain, facial pain, generalized pain, radicular pain, seizure, speech difficulties, syncope, tinnitus, tremors, vertigo,
vision change and weakness.
Psychiatric: anxiety, depression, disturbances of emotions, disturbances of memory, and hallucinations.
Endocrine: chills, excessive thirst or hunger, intolerance to cold, intolerance to heat, and thyroid problem.
NEUROLOGICAL P.T. ASSOCIATES
FRANKO & GORDANA STEPCIC, M.D., P.A.
Board Certified Neurologist
10231 Old Ocean City Blvd., Suite 101
Berlin, MD 21811
-----Telephone: (410) 641-2220
Fax: (410) 629-0348
Patient’s Name: ______________________________________________________
Last
First
M.I.
SSN: ___________-_______-____________
DOB: ______/______/________
Address: ___________________________________________________________
___________________________________________________________________
City
State
Zip Code
Home Number: __________________ Work/ Cell Number: __________________
E-Mail Address: _____________________________________________________
Employer Name & Address: ___________________________________________
Referring Doctor: ________________ Primary Doctor: ______________________
Emergency Contact (1): _______________________________________________
Relationship: _____________________ Phone Number: _____________________
Emergency Contact (2-Optional):________________________________________
Relationship: _____________________ Phone Number: _____________________
NEUROLOGICAL P.T. ASSOCIATES
FRANKO & GORDANA STEPCIC, M.D., P.A.
Board Certified Neurologist
10231 Old Ocean City Blvd., Suite 101
Berlin, MD 21811
-----Telephone: (410) 641-2220
Fax: (410) 629-0348
AUTHORIZATION TO RELEASE CONFIDENTIAL MEDICAL
INFORMATION FROM THE RECORD OF:
Patient’s Name: _____________________________________________________
Birth Date: _________________ Social Security Number: ___________________
I hereby authorize: Neurological P.T. Associates, Franko & Gordana Stepcic M.D., P.A.
or an authorized designee to release any and all information obtained regarding my medical
treatment or out-patient care during the provision of professional medical services. In addition, I
consent specifically to the release of any and all material containing psychiatric/ psychotherapy
records, mental health records and drug and/or alcohol history or treatment records. This
authorization specifically, but not exclusively, allows for the release of all such information to
other health care providers either currently or potentially involved in my care, the Social Security
Administration, my employer and to my insurance company which may be required for
completion of any claim in connection with my visits to this office. I hereby release all persons
or corporations supplying or handling such information from any liability or responsibility
whatsoever. I understand that I am not required to give this authorization and that I can refuse to
do so without prejudice to my future medical treatment. I understand that this authorization may
be revoked by me at any time, but unless this office is notified by me in person or via certified
mail of such revocation, shall be in effect from this date of initial signature and thenceforth. I
agree that a photo static copy of a fax transmittal of this authorization shall be considered as
effective and valid as the original.
________________________________________________________________________
Patient’s Printed Full Name
______________________________________________________________________________
Patient’s Signature Date:
______________________________________________________________________________
Signature of Responsible Party, when applicable
___________________________________________________
Responsible Party: Relationshipto Patient
NEUROLOGICAL P.T. ASSOCIATES
FRANKO & GORDANA STEPCIC, M.D., P.A.
Board Certified Neurologist
10231 Old Ocean City Blvd., Suite 101
Berlin, MD 21811
-----Telephone: (410) 641-2220
Fax: (410) 629-0348
OFFICE FINANCIAL POLICY AND AGREEMENT
Patient’s Full Name: _________________________________________________
Please Print
INSURANCE AUTHORIZATION AND ASSIGNMENT AGREEMENT
I hereby authorize: Neurological Rehab Associates, Franko & Gordana Stepcic, M.D., P.A. to
furnish information to my insurance carrier(s) concerning my illness and treatment and hereby
assign to the corporation all payments for medical services rendered to myself or my dependents.
SELF-PAY POLICY AND AGREEMENT
I agree and understand that payment is to be made in full at the time of service, unless other arrangements have
been made with Neurological Rehab Associates, Drs. Franko & Gordana Stepcic, M.D., P.A. If payment is not
made I understand that my account will be subject to the Collection Policy and Agreement stated below.
COLLECTION POLICY AGREEMENT
I understand that I am responsible for any amount not covered by my insurance including but not limited to,
copays and deductibles. I understand that I am responsible and agree to pay all reasonable collection costs
including but not limited to, reasonable collection agency fees (35 percent), attorney’s fees, and court costs.
Such fees represent administrative, accounting, bookkeeping, and account maintenance fees associated with
delinquent accounts. If court action is necessary to enforce payment, the venue shall be in Worcester County,
Maryland. A copy of this agreement shall be as valid as the original.
______________________________________________________________________________
Patient’s Signature
Date
NEUROLOGICAL P.T. ASSOCIATES
FRANKO & GORDANA STEPCIC, M.D., P.A.
Board Certified Neurologist
10231 Old Ocean City Blvd., Suite 101
Berlin, MD 21811
-----Telephone: (410) 641-2220
Fax: (410) 629-0348
Patient Acknowledgment Form
Use & Disclosure of Protected Health Information
Franko & Gordana Stepcic, MD, PA “Notice of Privacy Practices” provides information about how we
may use and disclose protected health information about you. Please acknowledge review and receipt, if
requested, of this office’s Notice of Privacy Practices by initialing below:
____________________________
Patient/Legal Guardian
Our Notice of Privacy Practices states that we reserve the right to change the terms described. Should
this happen, you will receive a revised copy, if requested, either by mail or at your next appointment.
_______________________________
Patient/Legal Guardian
You have the right to request restrictions on how your protected health information may be used or
disclosed for treatment, payment, or health care operations. We are not required to agree to your
restrictions, but if we do, we are both bound by our agreement with you.
_______________________________
Patient/Legal Guardian
By signing this form, you consent to our use and disclosure of protected health information about you for
treatment, payment, and health care operations. Other than activities that have already occurred, you may
revoke any further authorizations to use or disclose your health information.
Franko & Gordana Stepcic, MD, PA is authorized to discuss my medical health and treatment with:
_____________________________________________________________________________________
Name of Individual (if no one state “no one”) Relationship
_____________________________________________________________________________________
Signature of Patient/ Legal Guardian Date