2010/2011
Mr. / Mrs. / Ms. / Dr.
Last Name First Middle Today’s Date
/
Birth Date
Home Address
/
( )
Home Phone number
/ /
Social Security Number
City
Current Employer
State Zip Code
Employer Address
( )
Daytime/Other Phone number
May we leave a voicemail message?
Marital Status:  Single
( )


Yes  No 
E-mail
Yes, but leave only call back number
Married/partner (Name:_____________________)  Divorced


M
Widowed
 F
Person allowed to receive/discuss your medical information (optional) Relationship
Relationship Emergency contact person
Please fill out the following and check off the contacts to whom you would like us to send the report.
 Primary care doctor  Neurologist
( )
Telephone number
( )
Telephone number
Name
Street address
City
State Zip Code
Telephone
Name
Street address
City
State Zip Code
 Other doctor
Name
Street address
City
State Zip Code
( )
Telephone
( )
Telephone
( )
Name of referring physician:
Zip Code
( )
Phone number Street address City
Should we send a copy of our report to your physicians?
State
 YES  NO
(Reports cannot be sent without a complete mailing address)

I authorize the release of medical and other information to my insurance company for review of my coverage and/or for the processing of claims for services rendered to me.

I accept that it is my responsibility to provide all necessary insurance information to process payment of my claim. I authorize payment of my insurance benefits to be made directly to my physician. As a courtesy, my physicians’ office will submit claims to my insurance carriers, but I understand that I am financially responsible for all services rendered not covered or payable by my insurance carrier, including deductibles, co-payments or non-covered services.

If I need an authorization/referral, it is my responsibility to obtain it from my primary care physician prior to my appointment or I will be held responsible for payment of services rendered.

I understand that if I have BCBS mastermedical, no office coverage or no insurance, I will be expected to pay in full at the time medical services are rendered.
Signature of patient or legal representative Date
If signed by legal representative, relationship

Patient Name:______________________________ Date:______________________________
Symptomatic History:
Reason for today’s visit (diagnosis?):___________________________________________ Date of diagnosis:__________
What was/were your first symptom(s)? ________________________________________ When did it occur?__________
Who diagnosed you with the above condition(s)?  Primary Care Physician  Neurologist  Other____
2
Medical History: Please check any of the following illnesses which you have had
___ Stroke
___Heart attack
___ Sleep apnea
___ Seizures
___ High blood pressure
___ Diabetes ___ Asthma
___ Liver hepatitis ___ Pancreatitis
___ Depression/anxiety
___ Migraine
___ Angina
___ Emphysema
___ Anemia
___ Neuropathy
___ Syncope
___ Low/high Thyroid
___ Arthritis
___ Bipolar disorder ___ Schizophrenia
___ Head Trauma
___ High Cholesterol
___ Kidney failure
___ Cancer
___ Alcoholism
List other past or present illnesses not noted above:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Surgeries or Significant Trauma?  No  Yes (please describe, indicate year):
1. _____________________________________________
2. _____________________________________________
4. _____________________________________________
5. _____________________________________________
3. _____________________________________________ 6. _____________________________________________
Social History:
Years of education/highest degree_______  Most recent/primary occupation __________________________________________
 Currently working  Retired (year)___________  Disabled (year)___________
Living situation:
Smoking:


At home (with:_______________________)
Never  Yes
*If yes -  Cigarettes per day: _______
 Assisted living and # of years: _______
 Nursing facility
 Yes, but Quit (date: ________________)
Alcohol:  Never  Yes
*If yes -  Drinks/ week: ________
Gambling addiction?
 Yes, but Quit (date: ________________) and # of years: _______
Recreational Drugs:  Never  Yes (describe): _______________________________________
Are you currently driving?  No  Yes
 No  Yes
Family History: Please indicate family members (parents, siblings, children, grandparents, aunt/uncles/cousins) with any of the following conditions
Parkinson’s disease
Tremor
Huntington’s chorea
Obsessive compulsive disorder
Alzheimer’s or other dementia
Tourette/tic disorder
Other movement disorder/genetic disorder
Other neurological condition
Depression/suicide
Mental illness
Gait disorder or ataxia
Mental retardation
Dystonia
Stroke
Heart disease
Other
Parent
Father
Mother
Living
 Yes  No
 Yes  No
Present age or age at death Cause of death or significant illness
Allergies: Please list any allergies to prescription medications or x-ray contrast dye:  None
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Patient Name:_____________________________________________________ Date:______________________________ 3
Please list all current Medications:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Activities of Daily Living: Please indicate if you have difficulty in the following areas.
Normal Mild(infrequent, no help needed)
Moderate(occasional, may need some help)
Voice/Speech
Severe(frequent, requires assistance)
Marked(very frequent, unable to do)
Excess saliva/drooling
Swallowing
Handwriting
Feeding
Dressing
Bathing/toileting/hygiene
Turning in bed
Walking
Handling Medications
Shopping
Cooking/household chores
Handling finances/bills
Review of Symptoms: Please circle any current symptoms you currently have.
Constitutional: fatique/weakness, chills, sweats, hot flashes, weight loss, loss of appetite
Eye/ears/nose/throat: blurred vision, dry eyes, double vision, hearing loss, vertigo, choking, clear nasal drainage
Cardiac/pulmonary: chest pain, shortness of breath with activities, dizzy spells, palpitations, fainting, ankle swelling, wheezing, chronic cough
Gastrointestinal: nausea, vomiting, constipation, diarrhea, abdominal pain
Genitourinary: urine incontinence, urinary frequency, awakening to urinate, impotence
Musculoskeletal: muscle pain, joint pain, stiffness
Dermatological/ Allergy: Rash, itching, skin infection, decubitus ulcers
Neurological: headaches, numbness, tingling, limb weakness, lower back pain, cramps, muscle spasms, poor balance, falls, difficulty rising from a chair, tremor, loss of facial expression, word finding difficulty, impaired memory, confusion/disorientation
Endocrine: hair loss, dry skin, weight gain, edema
Hematological: bruising, blood clots, anemia, prolonged bleeding
Psychiatric: hallucinations, depression, anxiety attacks, forgetfulness, disorientation
Sleep: insomnia, sleep apnea/snoring, acting out /yelling in dreams, excessive daytime sleepiness, Restless Legs Syndrome