Patient’s Name:_______________________________________ Referring Doctor:___________________
Age: _____________ Right or Left handed Race: ______________ Gender:
Male
or
Female
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: __________________________________________________________________________________
Siblings Health: _______________________________________________________________________________________________
Social History:
Marital Status: Married
Divorced
Widowed
Occupation: ____________________________ or Retired
Tobacco Usage: Cigarette
Pipe
Cigar Chew
Alcohol Consumption:
Beer Wine
Hard Liquor
Separated
Single
Amount Per Day_________________________________
Amount Per Week: ______________________________
Review of Systems
Constitutional: anorexia, chills, diaphoresis, fatigue, fever, insomnia, night sweats, weakness, weight gain/obesity and weight loss.
Eyes: blindness, double vision, 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, 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 and shortness of breath.
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, myalgias, neck pain, sciatica and stiffness.
Dermatologic: itching, changing moles, growths, rash, scar 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, neck pain, pain, back, pain, facial, radicular pain, seizure,
speech difficulties, syncope, tinnitus, tremor, vertigo, vision change and weakness.
Psychiatric: anxiety and depression.
Endocrine: chills, excessive thirst or hunger, intolerance to cold, intolerance to heat and thiroid problem.
Hematologic/Lymphatic: abnormal bleeding and bruising, anemia and lymph node enlargement/mass.
Allergy/Immunology: anaphylactoid reaction
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: __________________________________________________________
Street
City
State
Zip Code
Home Number: __________________ Work/ Cell Number: _________________
Employer Name & Address: ___________________________________________
Referring Doctor: ________________ Primary Doctor: _____________________
Whom may we contact in the event of an emergency?: ______________________
Relationship: _________________________ Phone Number(s): ______________
__________________________________________________________________
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
INSURANCE AUTHORIZATION AND ASSIGNMENT
Patient’s Full Name: _________________________________________________
Please Print
I hereby authorize: Neurological P.T. 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 dependants.
I understand that I am responsible for any amount not covered by my insurance and for any fees
expended by the corporation for collection of any outstanding bill.
Please Sign and return so that we can bill for services rendered. Thank you.
______________________________________________________________________________
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