Health System
P A T I E N T INFORMATION
How did you hear about us?_
Marital Status: S - M - D - W
Name:
Middle Initial
How would you like to be addressed by our staff?_
Address:
Social Security #:
Slate
Date of Birth:
Zip
Mailing Address: • As above
Birth Country or State:
Ethnicity & Race:
Religious Preference: _
E-Mail address:.
Name of Spouse:
Phone:
Home
Primary Care MD:
Work
Cell
Preferred Pharmacy:.
Occupation:.
Person To Contact In Case of Emergency
Employer:
Name:
Employer's Address:
Relationship:
Phone:
Subscriber of Insurance/Name of Policy Holder:_
Middle Initial
Address:
Date of Birth:
SS#:
Employer:,
Address:
Employer Phone Number:.
I have insurance coverage and assign directly to U C Regents all surgical and/or medical benefits, if any, otherwise
payable to me for services rendered. I understand that I am financially responsible for all charges whether or not
paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of
benefits.
Signature of Patient, Parent or Guardian
I
Date
Health System
G E N E R A L N E U R O L O G Y CLINIC QUESTIONNAIRE
Department of Neurology
PATIENT INFORMATION
Last, First, Middle Name
Aqe
Today's Date
Sex:
Birth Date
Native Language:
Male / Female
Referring Physician's Full Name
Telephone #:
Physician's Address
Are you:
Right-handed
Left-handed
Ambidextrous
Why do you need to see a Neurology specialist?
Past Medical History
Date Diagnosed
Hospitalizations, Operations and dates
njuries and dates. Include any episodes of loss of consciousness.
3lood Transfusions and dates
Drug Allergies and reactions:
UCLA Form #31574-
Rev. (04/10)
P a g e l of 4
E3IP Health System
G E N E R A L N E U R O L O G Y CLINIC QUESTIONNAIRE
Department of Neurology
Medications (current and/or recent)
Name
How often?
Dosage
(* Attached typed sheet/write on back if necessary)
Dietary SupplementsA/itamins:
Dose & Frequency
Name
Social History
Any use of tobacco (type, and for how long)?
Any use of caffeinated beverages?
Any use of alcohol (type and for how long)?
Any use of recreational drugs (type and for how long)?
Any exposure to toxins/poisonous substances at work or with hobbies?
What type of work do you do?
Education:
Grade School
Marital Status:
Single
High School
Married
College
Divorced
Post-Graduate
Voc. Training
Separated
Widowed
Birthplace:
UCLA Form #31574
Rev. (04710)
Page 2 of 4
G E N E R A L N E U R O L O G Y CLINIC QUESTIONNAIRE
Department of Neurology
FAMILY HISTORY
Mother: Living or deceased?
Health Problems:
Age:
Father: Living or deceased?
Health Problems:
Age:
Brothers/Sisters: List from the oldest to youngest.
1. Brother or sister?
Living or deceased?
Age:
2. Brother or sister?
Health problems:
Living or deceased?
Age:
3. Brother orsister?
Health problems:
Living or deceased?
Age:
4'. Brother or sister?
Health problems:
Living or deceased?
Age:
Health problems:
Children: List from oldest to youngest.
1. Daughter or son?
Health problems:
Living or deceased?
Age:
2. Daughter or son?
Health problems:
Living or deceased?
'
Age:
3. Daughter or son?
Health problems:
Living or deceased?
Age:
Have any of your family or relative had the following health conditions? If yes, whom?
Heart disease
High blood pressure
High cholesterol
Loss of memory
Epilepsy/seizures
Depression
Mental disease
Muscle weakness
Other:
;
.
;
Stroke
i
Fainting
Diabetes
Cancer
Multiple sclerosis
Polio
Limping
Thyroid disease
THANK Y O U V E R Y MUCH F O R COMPLETING THIS QUESTIONNAIRE.
B E S U R E TO BRING IT TO Y O U R D O C T O R ' S APPOINTMENT
UCLA Form #31574
Rev. (04/10)
Page 3 of 4
Health System
G E N E R A L N E U R O L O G Y CLINIC QUESTIONNAIRE
Department of Neurology
REVIEW S Y S T E M S
Please place a checkmark if you currently have any of the following symptoms.
1. "constitutional"
•
fever
•
weight loss
•
fatigue
2. "eyes problem"
•
•
blurred vision
eye pain
•
•
double vision
eye redness
•
•
loss of vision
eye dryness
3. "ear/nose/throat"
•
•
•
trouble hearing
loss of balance
hoarseness
•
•
•
ringing in ear(s)
ear pain
trouble swallowing
•
•
•
dizziness (vertigo)
ear discharge
slurred speech
4. "cardiovascular"
•
chest pain
•
irregular heart beat
•
fast heart beat
•
limb swelling
•
limb pain on walking
•
fainting
•
trouble breathing
n chronic cough
•
coughing blood
•
•
•
O
indigestion
nausea
diarrhea
incontinence
•
•
heart bum
vomiting
•
constipation
•
•
•
•
abdominal pain
regurgitation
bloody stools
blood in urine
8. "musculoskeletal"
•
•
•
• pain on urination
muscle pain
cramp
loss of muscle bulk Q
• muscle
neck pain
• joint stiffness
joint pain
L7J muscle twitches'
• back pain
• joint swelling
9.
•
numbness
•
tingling
•
discoloration
10. "neurologic"
•
•
•
headache
weakness
blackouts
•
•
•
face pain
tremors'
trouble with memory
•
•
•
face numbness
clumsiness
trouble concentrating
11. "psychiatric"
•
•
hallucinations
suicidal thoughts
•
•
feeling depressed
inappropriate crying
•
trouble sleeping
•
inappropriate laughing
•
lumps or swellings
5. "respiratory"
6. "gastrointestinal"
7. "genitourinary"
"skin & breast"
12. "hematologic/lymphatic" •
abnormal bleeding •
nosebleeds
13. "allergic/immunologic"
•
skin rash
• joint pain
14. "endocrine"
•
excessive thirst
•
•
heat or cold intolerance •
Person completing questionnaire
dry eyes & or dry mouth
excessive urination
Relationship to patient:
For office use: This questionnaire may be completed by the patient, relative or ancillary staff provided that it is
signed and dated by the treating physician. (Reference may later be made to this information by a signed and
dated statement by the treating physician, designating location of the information, date obtained and any
subsequent charges.)
—++++++++++++++++++++++4-+
Physician's Signature:
UCLA Form #31574
R E V . (04/10)
f++++++++++++-i-+++++++++++-
-+-H-+++++++-H4-
Date:
Time:
Page 4 of 4
SGEI
Health
NOTICE OFPRIVACY PRACTICES
Effective Date: September 23, 2013
NOTICE OF.PRJVACY PRACTICES ACKNOWLEDGMENT OF RECEIPT
The UCLA Health Notice of Privacy Practices provides information about how we may use and
disclose protected health information about you.
In addition to the copy we are providing you, copies of the current notice are available by
accessing our website at www.uclahealth.org and may be obtained throughout the UCLA
Health.
I acknowledge that I have received the Notice of Privacy Practices.
Signature of Patient or Patient's Representative
Date
Time'
Print Name
Relationship to Patient
Interpreter (if applicable)
Interpreter ID #
C O M P L E T E IF W R I T T E N A C K N O W L E D G M E N T W A S NOT OBTAINED
Please document your efforts to obtain acknowledgment and reason it was not obtained
(please initial).
1.
Notice of. Privacy Practices Given - Patient Unable to Sign .
2.
Notice of Privacy Practices Given - Patient Declined to Sign
3.
Notice of Privacy Practices and Acknowledgment Mailed to Patient
4. Other Reason Patient Did Not Sign:
}•
Signature of UCLA Health Representative
Date
Print Name
Department
U C L A Form # 5 0 0 0 0
Rev. (10/13)
I
i Signed Chart Copy
•
Patient Copy
Time
Page 9 of 9
T E R M S AMD C O N D I T I O N S O F S E R V I C E
CONFIDENTIALITY O F INFORMATION
.-,.,..„„
ADMISSION AND MEDICAL SERVICES AGREEMENT - READ CAREFULLY BEFORE SIGNING
NOTICE TO CONSUMERS: Medical doctors, including your physician, are licensed
and regulated by the Medical Board of California. For information you may call the
Board at (800) S33-2322 or visit its website at http://vvVAV.mbc.ca.gov.
I have read, agreed to and received a copy of this Terms and Conditions of Service.
• Signature of Patient or Patient Representative
Date
Time
Signature of Witness (required if patient unable to sign)
Date
Time
Signature of Interpreter
Date
Time
Relationship of Representative to Patient
Interpreter ID #
Language Used
Financial R e s p o n s i b i l i t y A g r e e m e n t by P e r s o n Other t h a n the Patient or the Patient's
Legal R e p r e s e n t a t i v e
1 agree to accept financial responsibility for sea/ices rendered to the patient and to accept the
terms of the Financial Agreement (Paragraph 7) and Assignment Of Benefits (Including Medicare
Benefits) (Paragraph 8) set forth above.
Date
lime
Financially-Responsible Party
Witness
PATIENT RIGHTS NOTICE: (applies to inpatient admissions only)
Would you like your agent under a durable power of attorney for health care or your next of kin
to receive a copy of the Patient Rights and Responsibilities Notice? If so, please contact the
Patient Affairs Department at (310) 267-9113.
ADVANCED DIRECTIVES:
I have an advance directive for health care (e.g., Power of Attorney for Health Care). Yes •
1 have provided UCLAH with a current copy of my advance directive.
Yes •
No •
No •
If "No", I understand it is my responsibility to provide UCLAH a current copy of my advance
directive. If I want to express my health care wishes, 1 understand I should speak to my health
care provider.
UCLA Form #305949
Rev. (2/13)
Signed Chart Copy
O
Patient Copy
•
Page 3 of 5