ADULT AND PEDIATRIC NEUROSURGERY, P.C.
Petra Gurtner, M.D.
Tina C. Rodrigue, M.D.
PATIENT INFORMATION SHEET
Patient Name: ____________________________________________________ Today’s Date: ____________________
Address: ___________________________________________ City: _________________ State: _____ Zip: _________
Home Phone: _________________ Cell: ___________________ Age: _____ Date of Birth: __________ Sex: M or F
Patient’s SSN: ____________________ Marital Status (circle one): Married Divorced Single Widowed Separated
Patient’s Employer: _____________________________________________ Work Phone: _______________________
Spouse’s Name: ______________________________ Spouse’s Date of Birth: ________ SSN: __________________
Emergency Contact: _______________________ Relationship to You: _______________ Phone: _______________
Parent/Guardian if Patient is a Child: ________________________ DOB: _______________ SSN: ________________
Guarantor’s Address: ______________________________________________________________________________
Name of Your Family or Primary Physician: ___________________________________ Phone: _________________
Name of Physician Requesting this Consultation: _______________________________ Phone: _________________
Chief Complaint/Reason for Being Seen: ______________________________________________________________
INSURANCE INFORMATION
Primary Insurance: ______________________________________ Policy #: ___________________________________
Subscriber Name: _________________________ Patient’s Relationship to Subscriber: _________ Group#: _______
Secondary Insurance: ___________________________________ Policy #: ___________________________________
Subscriber Name: _________________________ Patient’s Relationship to Subscriber: _________ Group#: _______
ACCIDENT INFORMATION
Is your current problem a result of an accident? ________________________________ If yes, check all that apply:
CAR ACCIDENT _____ WORK ACCIDENT ______ OTHER ACCIDENT ____ Please Explain: _____________________
_________________________________________________________________________________________________
Date of injury: ______________ Claim#:________________________ Claims Adjuster: _________________________
Company Name to send claims: _____________________________________________ Phone: _________________
Address for Claims: ________________________________________________________________________________
How long have you been employed with the company in which the workman’s comp claim has been filed?: ___________
Last day worked?: _________________________________________________________________________________
I hereby authorize Petra Gurtner, M.D./Tina Rodrigue, M.D. and/or designates to provide the patient above treatment. I also
authorize release of medical and/or financial information as is necessary for filing insurance. I authorize direct payment from
said insurer(s) to this practice. I agree to be responsible for payment of all charges incurred. Should collection become
necessary, I agree to be responsible for all costs of collection including attorney fees of 33 1/3% of the outstanding bill.
____________________________________________________
PATIENT/GUARANTOR SIGNATURE
__________________________
RELATIONSHIP
___________________
DATE
Adult and Pediatric Neurosurgery, P.C.
Petra Gurtner, M.D.
Tina C. Rodrigue, M.D.
248 W. Bute St., Suite 100, Norfolk, VA 23510
Phone: 757-622-1003 Fax: 757-622-1108
AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION
Patient’s Name:
Date of Birth:
Previous Name:
Social Security #:
I request and authorize
release healthcare information of the patient named above to:
to
Name:
Address:
City:
State:
Zip Code:
This request and authorization applies to:
 Healthcare information relating to the following treatment, condition, or
dates:
 All healthcare information
 Other:
Definition: Sexually Transmitted Disease (STD) as defined by law, RCW 70.24 et seq., includes herpes, herpes
simplex, human papilloma virus, wart, genital wart, condyloma, Chlamydia, non-specific urethritis, syphilis, VDRL,
chancroid, lymphogranuloma venereuem, HIV (Human Immunodeficiency Virus), AIDS (Acquired
Immunodeficiency Syndrome), and gonorrhea.
 Yes  No
I authorize the release of my STD results, HIV/AIDS testing, whether negative or positive, to
the person(s) listed above. I understand that the person(s) listed above will be notified that I
must give specific written permission before disclosure of these test results to anyone.
 Yes  No
I authorize the release of any records regarding drug, alcohol, or mental health treatment to
the person(s) listed above.
Patient Signature:
Date Signed:
Adult and Pediatric Neurosurgery, P.C.
Petra Gurtner, M.D.
Tina C. Rodrigue, M.D.
248 W. Bute Street, Suite 100
Norfolk, Virginia 23510
Phone:757-622-1003
Fax: 757-622-1108
Disability, FMLA, Insurance and Medical Records Policy
February 1, 2007
Disability Forms, Insurance Forms, and FMLA Forms: We will be happy to
complete these forms for you. Please fill out all personal information on all
forms before presenting them to the office. Allow at LEAST TWO WEEKS for
completion of forms. The following pre-paid charges will apply:
First Form, one page
$20.00
First Form, multi page
$35.00
Subsequent forms, one page
(monthly, or recurring)
$10.00
Subsequent forms, multi page
(monthly, or recurring)
$15.00
Medical Record Copies: We will be happy to provide copies of your medical
records at your request. These records will be released to you or your
authorized agent. A Medical Records Release Form is required before this
information can be released. Please allow at LEAST TWO WEEKS for these
records to be released. The following pre-paid charges will apply:
Patient Requests
$0.00
Base charge (chart retrieval, copying,
postage, and labor)
$10.00
Pages 1 – 50
$.50 per page
Pages 51 and over
$.25 per page
I have read the above policy of Adult & Pediatric Neurosurgery, and understand that it applies
to all forms, and medical records.
Patient Signature: _______________________________________ Date: ___________________________
ADULT AND PEDIATRIC NEUROSURGERY, P.C.
PETRA GURTNER, M.D., TINA RODRIGUE, M.D.
PATIENT HEALTH HISTORY
Patient Name: ______________________________________________ DOB: ________________________
Referred by: ____________________________ Primary Care Physician: ___________________________
Reason for Today’s Visit (Chief Complaint): ___________________________________________________
Height: _____________________________________ Weight: ____________________________________
Is your current problem the result of an injury? Please check below all that apply:
_____ Car Accident
_____ Work Accident
_____ Other Accident
PAST MEDICAL HISTORY
Please list any prior major illnesses and/or injuries: ____________________________________________
Surgeries/Hospitalizations
Year
Have you ever had any problems with anesthesia?
Current Medications
Complications
_____Yes
Dose
_____ No
Frequency
Allergies to Medications: __________________________________________________________________
FAMILY HISTORY
Family Member
Alive/Deceased
Grandmother (Mom’s)
Grandfather (Mom’s)
Grandmother (Dad’s)
Grandfather (Dad’s)
A
A
A
A
D
D
D
D
Father
A
D
Mother
A
D
Sister/Brother
A
D
Sister/Brother
A
D
Age
Health Status or Cause of Death
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ADULT AND PEDIATRIC NEUROSURGERY, P.C.
PETRA GURTNER, M.D., TINA RODRIGUE, M.D.
PATIENT HEALTH HISTORY
Patient Name: ______________________________________________ DOB: ________________________
SOCIAL HISTORY
Occupation: _____________________________________________________________________________
Marital Status:
___ Single
Do you have children:
___ Married
___ No
Do you live alone?: ___ No
___ Yes
___ Yes
___ Separated
____ Divorced
___ Widowed
How Many?: ____________________________________
Who lives with you?: _____________________________
Do you smoke cigarettes?
_____ No, I have never smoked cigarettes.
_____ No, I quit ____ years ago. At that time I was smoking __ pks per day for ____ years.
_____ Yes, I smoke____ packs of cigarettes per day for ____ years.
Do you smoke cigars or a pipe?
__ No
___ Yes
How often? _______ How many years? ________
Do you drink alcohol?
____ No, never (or rarely).
____ No, but I used to. Explain: _________________________________________________
____ Yes. If yes, how often?
____ Daily
____ 1 or more times a week.
_____ 1 or more times a month.
Are you at risk for AIDS (e.g., sexual orientation, drug abuse, previous blood transfusion)?
____ No
___ Yes.
Please Explain: ______________________________________________
REVIEW OF SYSTEMS
Are you currently, or have you ever had problems with:
(Circle Yes or No)
CONSTITUTIONAL
Fever ___________________________
Excessive Fatigue ________________
Yes/No
Yes/No
Weight Loss ____________________
Night Sweats ___________________
EYES
Infections _______________________
Glaucoma _______________________
Wear Glasses ____________________
Yes/No
Yes/No
Yes/No
Injuries ________________________
Yes/No
Cataracts ______________________
Yes/No
Date of Last Eye Exam _____________________
Yes/No
Yes/No
Yes/No
Ear Pain _______________________
Yes/No
Ringing in Ear (Right/Left) ________
Yes/No
Nasal Drainage __________________
Yes/No
Amount ________ Color________
Nasal Congestion _______________
Yes/No
Sinus Problems _________________
Yes/No
Sore Throat ____________________
Yes/No
Date of Last Exam _________________________
EARS, NOSE, THROAT AND MOUTH
Wear Hearing Aids ________________
Hearing Loss ____________________
Ear Infections ____________________
Balance Disturbances (e.g., Vertigo)
Spinning __________________
Nose Bleeds _____________________
Inability to Smell _________________
Sinus Headaches _________________
Mouth Sores _____________________
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
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Yes/No
Yes/No
ADULT AND PEDIATRIC NEUROSURGERY, P.C.
PETRA GURTNER, M.D., TINA RODRIGUE, M.D.
PATIENT HEALTH HISTORY
Patient Name: ______________________________________________ DOB: ________________________
CARDIOVASCULAR
High Blood Pressure ______________
Heart Murmur ____________________
Swelling in Feet or Hands __________
Chest Pain or Angina _____________
Yes/No
Yes/No
Yes/No
Yes/No
Irregular Pulse __________________
Yes/No
High Cholesterol ________________
Yes/No
Leg Pain While Walking __________
Yes/No
Date of last EKG __________________________
RESPIRATORY
Asthma _________________________
Yes/No
Emphysema _____________________
Yes/No
Bronchitis _______________________
Yes/No
Lung Cancer _____________________
Yes/No
Date of Last Chest X-ray ____________________
Chronic Cough __________________
Shortness of Breath _____________
Pneumonia _____________________
Bloody Sputum _________________
Yes/No
Yes/No
Yes/No
Yes/No
GASTROINTESTINAL
Indigestion or Pain w/Eating________
Vomiting ________________________
Liver Disease ____________________
Abdominal Pain __________________
Ulcers or Gastritis ________________
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Nausea ________________________
Blood in Your Vomit _____________
Jaundice _______________________
Change in your Bowel Habits ______
Colon Cancer ___________________
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
GENITOURINARY
Urinary Tract Infections ___________
Blood in Your Urine _______________
Incontinence_____________________
Prostate Cancer (males) ___________
Uterine or Cervical Cancer (females) _
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Painful Urination ________________
Difficulty Starting or Stopping Stream
Kidney Stones __________________
Endometriosis __________________
Yes/No
Yes/No
Yes/No
Yes/No
MUSCULOSKELETAL
Arm or Leg Weakness _____________
Arm or Leg Pain __________________
Arthritis _________________________
Yes/No
Yes/No
Yes/No
Back Pain ______________________
Yes/No
Joint Pain or Swelling ____________
Yes/No
Broken Bones __________________
Yes/No
List: ___________________________________
INTEGUMENTARY
Skin Disease_____________________
Nipple Discharge (females)_________
Yes/No
Yes/No
NEUROLOGICAL
Fainting Spells or “Black Outs” _____
Problems with your Memory________
Difficulty with your Speech_________
Double or Blurred Vision __________
Coordination in Arm and/or Legs____
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Skin Cancer ____________________
Yes/No
Breast Pain, Tenderness/Swelling
(females) _________________
Yes/No
Date and Results of Last Mammogram (females) _______________________________________________
Seizures _______________________
Disorientation __________________
Inability to Concentrate ___________
Face Weakness _________________
Yes/No
Yes/No
Yes/No
Yes/No
PSYCHIATRIC
Anxiety _________________________
Yes/No
Depression _____________________
Yes/No
Other Psychiatric Disorder or Treatment _____________________________________________________
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ADULT AND PEDIATRIC NEUROSURGERY, P.C.
PETRA GURTNER, M.D., TINA RODRIGUE, M.D.
PATIENT HEALTH HISTORY
Patient Name: ______________________________________________ DOB: ________________________
ENDOCRINE
Diabetes ________________________
Increased Appetite________________
Excessive Thirst or Urination _______
Yes/No
Yes/No
Yes/No
Thyroid Disease _________________
Hormone Problems ______________
Yes/No
Yes/No
HEMATOLOGIC/LYMPHATIC
Anemia _________________________
Yes/No
Bleeding Tendencies ______________
Yes/No
Blood Transfusion ________________
Yes/No
If yes, when? _____________________________
Hemophilia _____________________
Persistent Swollen Glands or Lymph
Nodes ___________________
Yes/No
ALLERGIC/IMMUNOLOGIC
Food Allergies ___________________
Inhalant (Nasal) Allergies __________
Immunologic Disorders____________
List _____________________________________
List _____________________________________
Yes/No
Yes/No
Yes/No
Yes/No
THE ABOVE INFORMATION IS ACCURATE TO THE BEST OF MY KNOWLEDGE.
______________________________________________
PATIENT SIGNATURE
___________________________________
DATE
______________________________________________
PATIENT SIGNATURE
___________________________________
DATE
______________________________________________
PATIENT SIGNATURE
___________________________________
DATE
I HAVE REVIEWED THE ABOVE INFORMATION WITH THE PATIENT.
______________________________________________
PHYSICIAN SIGNATURE
___________________________________
DATE
______________________________________________
PHYSICIAN SIGNATURE
___________________________________
DATE
______________________________________________
PHYSICIAN SIGNATURE
___________________________________
DATE
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