New Patient Packet. Drake D. Duane, MS, MD. Drake D. Duane, MS, MD. Patient Name:

Transcription

1 Institute for Behavioral Neurology New Patient Packet Patient Name:

2 Institute for Behavioral Neurology NEW PATIENT INFORMATION FORM PATIENT INFORMATION PATIENT FULL NAME: TODAY S DATE: DOB: AGE: MARITAL STATUS: SEX: HOME PHONE: MOBILE PHONE: CURRENT ADDRESS: City: HIGHEST EDUCATION COMPLETED: State Zip: SCHOOL/ INSTITUTION: PARENT/GUARDIAN/RESPONSIBLE PARTY NAME: ADDRESS: (If Different) City: State: Zip: ATTENDING/PRIMARY CARE PHYSICIAN: EMERGENCY CONTACT: PHONE: RELATIONSHIP:

3 Institute for Behavioral Neurology PRIMARY INSURANCE Policy Company ID # Policy Address Group # Policy City Policy Holder Policy Zip Relationship SECONDARY INSURANCE Policy Company ID # Policy Address Group # Policy City Policy Holder Policy Zip Relationship REASON FOR APPOINTMENT: CURRENT MEDICATIONS: SIDE EFFECTS/CONCERNS IF ANY, YOU ASCRIBE TO MEDICATION(S): OTHER METHODS OF TREATMENT: PERTINENT FAMILY HISTORY:

4 Institute for Behavioral Neurology MEDICAL BACKGROUND INFORMATION Please answer the following questions and bring this record to your examination. It will help your physician to know not only about your health but also about your family and relatives. Religion: Occupation: Education: How long? Age on Completion: Where and when have you traveled outside the U.S. and Canada? Father Living: Mother YES NO Living: Spouse YES NO Living: YES NO Age or age at Death: Age or age at Death: Age or age at Death: Present Health or Cause of Death:. Present Health or Cause of Death:. Present Health or Cause of Death: Brothers Sisters Children # Living: # Living: # Living: # Deceased: # Deceased: # Deceased: Present Health or Cause of Death:. Present Health or Cause of Death:. Present Health or Cause of Death:.

5 Institute for Behavioral Neurology Please select illnesses which have occurred in any YOURSELF or YOUR BLOOD RELATIVES (parents, grandparents, uncles, aunts, siblings, and children) Diabetes Allergy Manic-depression Parkinson's disease Scoliosis Immune disorder High blood pressure Breast/ovary/uterus disease Psychosis Alzheimer's Learning disability Lupus eiythematosis Stroke Schizophrenia Eating disorder Seizures (Febrile) Hyperactivity Ulcerative colitis Heart attack Alcoholism Obsessive-compulsive disorder Sleep disorder Attention Deficit Rheumatoid arthritis Thyroid disorder Panic attack Tremors Daytime sleepiness Myasthenia gravis Cancer Post-partum depression Migraine Tourette syndrome Pernicious anemia Kidney disease Depression Tics Dystonia Psoriasis Auto-Immune

6 Institute for Behavioral Neurology Please list other illnesses not requiring operation for which you were hospitalized. Have you had serious injuries, broken bones, etc? If Yes List type and date: Have you had allergy or sensitivity to medicines or other substances? If yes, please Describe: Do you use tobacco now or past? Type and daily amount: Please check the diseases against which you have been immunized Pneumonia Tetanus Typhoid Polio Influenza Other: Surgeries Previous Operations: Date: Hospital: Surgeon: Dental Please list if you have any dental problems now Medications Please name or otherwise identify medicines now or recently used.

7 Institute for Behavioral Neurology Menstrual Last period: Periods are: Number of pregnancies: Number of miscarriages: Have you taken? Cortisone-type drugs Oral contraceptives Radiation therapy Blood transfusion Date Your weight dressed How long have you been at this weight? Your height: Staff Use Only Reviewed Date Name Mayo Clinic Number, if one

8 Institute for Behavioral Neurology PROFILE OF INTERESTS AND APTITUDES For each of the below aptitudes, interests, subjects, rate yourself in one of the five categories give. Superior Above average Average Below average Poor (composition) Foreign Language Penmanship quality Arithmetic ematical reasoning Algebra Business Geometry Geography Biological sciences Physical sciences Typing Mechanics (shop/woodworking) istic (drawing/sculpting) (singing/instrumental) Computers Name Date

9 Institute for Behavioral Neurology EDINBURGH HANDEDNESS INVENTORY Name Date Of Birth Sex Please indicate your preferences in the use of hands in the following activities by putting a + in the appropriate column. Where the preference is so strong that you would never try to use the other hand unless absolutely forced, put ++. If in any case you are really indifferent, put + in both columns. Some of the activities require both hands. In these cases, the part of the task or object for which hand preference is wanted is indicated in the brackets. Please try to answer all the questions and only leave blank if you have no experience at all of the object or task. Left Right Drawing Throwing Scissors Toothbrush Knife (without fork) Spoon Broom (upper hand) Striking a match (match) Opening a box (lid) Which foot do you prefer to kick with? Which eye do you use when using one? (Leave blank) LQ: Decile: Please indicate your eye color: Gray Blue Green Hazel Brown

10 Institute for Behavioral Neurology CHILD DEVELOPMENT AND FAMILY HISTORY QUESTIONNAIRE Patient Name: Patient DOB: Completed By: Date Patient Age PRENATAL HISTORY (Circle all appropriate) Activity in Utero Was this a multiple birth pregnancy? Baby s Position Was this a multiple birth pregnancy? General description of mother s health during pregnancy: Medications used during pregnancy: Low Average Yes High If Yes, how many? rmal Breech Other: Yes If Yes, how many? rmal Equivocal High Risk (Specify): ne Minor vitamins/over the counter Prescription drugs (specify):

11 Institute for Behavioral Neurology CHILD DEVELOPMENT AND FAMILY HISTORY Premature rmal Late Term Length: <36 weeks weeks >39 weeks Duration of labor <12 hours hours >24 hours Medications at labor: ne Minor sedatives Pitocin drip Method of delivery Vaginal Forceps C-section Birth Weight Low (<6lbs) rmal (6-10lbs) Major drugs (specify): High (>10lbs) Apgar scores Prenatal Continued Obstetrician concerns about the delivery? Was a pediatrician called in? Yes If So, why? Yes Was there jaundice? If so, was ultra violet light therapy for jaundice used? Was there AB incompatibility? Was there RH incompatibility? Yes Yes

12 Institute for Behavioral Neurology Was there any surgery in infancy or childhood? If so, what type? Were there frequent middle ear infections? Yes If so, what type? : Yes If yes, 2-3 per year or 2-3per year? : As an overall statement, characterize the child s development Average Possibly Abnormal Definitely Abnormal Please explain or provide a brief statement for the following: Age at which each stage occurred and a qualifying statement as to quality or characteristics of that activity, i.e. average, poor, or odd. For example: first steps at age 12 months, very uncoordinated As an overall statement, characterize the child s development Average Possibly Abnormal Definitely Abnormal 1. Body build in infancy and early childhood: rmal Small Large Thin Obese 1. Infant temperament: rmal Hyperactive Hypoactive

13 Institute for Behavioral Neurology Age: 4. Creep: rmal Early Delayed 5. Crawl: rmal Early Delayed 6. Cruise rmal Early Delayed 7. First steps: rmal Early Delayed 8. Gait (walking) rmal Early Delayed 9. First words: rmal Early Delayed 10. First sentences: rmal Early Delayed 11. Toilet trained: rmal Early Delayed Infant feeding habit: rmal Reduced High Quality: Colicky 12. Last age of nighttime bedwetting: 13. Was there abnormality in pronouncing words? 14. Any nighttime sleep disturbances (nightmares, sleep walking, erratic sleep)? ne Occasionally Frequently 15. Were there any unusual drug reactions to: Antihistamines Bronchodilators (anti-asthma) Anticonvulsants ne Other (please specify drug and reaction):

14 Institute for Behavioral Neurology 16. Please select any anticonvulsants previously prescribed: Ativan (lorazepam) Carbatrol (carbamazepine) Depakote (valproic acid) Diastat (diazepam) Dilantin (phenytoin) Gabitril (tiagabine) Keppra (levetiracetam) Klonopin (clonazepam) Lamictal (lamotrigine) Lyrica (pregabalin) Mysoline (primidone) Neurontin (gabapentin) Onfi (clobazam) Phenobarbital Tegretol (carbamazepine) Trileptal (oxcarbazepine) Valium (diazepam) Vimpat (lacosamide) Zonegran (zonisamide) ne Other: 17. Please select any behavioral medications previously prescribed: Abilify (aripiprazole) Adderall Ambien (zolpidem) Buspar (buspirone) Celexa (citalopram) Concerta (methylphenidate) Cymbalta (duloxetine) Dexedrine Effexor (venlafaxine) Focalin (dexmethylphenidate) Geodon (ziprasidone) Lexapro (escitalopram) Lithium / Lithium Carbonate Lunesta (eszopiclone) Luvox (fluvoxamine) Metadate (methylphenidate) Methylin (methylphenidate) Nuvigil (armodafinil) Orap (pimozide) Paxil (paroxetine) Pristiq (desvenlafaxine) Provigil (modafinil) Prozac (fluoxetine) Risperdal (risperidone) Ritalin (methylphenidate)q Seroquel (quetiapine) Tofranil (imipramine) Trazodone Viibryd (vilazodone) Vyvanse (lisdexamfetamine) Wellbutrin (buproprion) Xanax (alprazolam) Zoloft (sertraline) Zyprexa (olanzapine) ne Other:

15 Institute for Behavioral Neurology 18. Please circle any other neurological medications previously prescribed: Axert (almotriptan) Aricept (donepezil) Cogentin (benztropine) Comtan (entacapone) Ergoloid Exelon (rivastigmine) Frova (frovatriptan) Imitrex (sumatriptan) Kemadrin (procyclidine) Levsin (hyoscyamine) Maxalt (rizatriptan) Mirapex (pramipexole) Namenda (memantine) Piracetam (nootropil) Sinemet (carbadopa/levodopa) Skelaxin (metaxalone) Stalevo (carbadopa/levodopa/entacapone) Xenazine (tetrabenazine) ne Other: 19. Has there ever been a seizure, febrile or otherwise? If so when? 20. Has there ever been a closed or open head injury which resulted in fracture and/or loss of consciousness? If so, when? 21. Was there ever an accidental ingestion of medicine in childhood? 22. Was there ever a central nervous system infection (meningitis, encephalitis)? Preschool Experience 23. Was preschool ever attended? If so, where, at what age and for how long? 24. Was there concern by preschool staff regarding readiness for kindergarten? 25. Specify the nature of the concern (i.e. speech, behavior, coordination, hyperactivity):

16 Institute for Behavioral Neurology Early School 26. Were concerns raised by teachers? In grades K through 3? Possible Definitely If so, were the concerns: academics (i.e. reading, math); restlessness (hyperactivity); lack of attention; awkwardness or incoordination; social interaction; other (please specify): 27. In late elementary school were concerns raised by teachers? Possible Definitely If so, were the concerns: academics (i.e. reading, math); restlessness (hyperactivity); lack of attention; awkwardness or incoordination; social interaction; other (please specify): 28. Were concerns raised by teachers in Junior High/ Middle School? Possible Definitely If so, were the concerns: academics (i.e. reading, math); restlessness (hyperactivity); lack of attention; awkwardness or incoordination; social interaction; other (please specify): 29. Were concerns raised by teachers in High School? Possible Definitely If so, were the concerns: academics (i.e. reading, math); restlessness (hyperactivity); lack of attention; awkwardness or in coordination; social interaction; other (please specify):

17 Institute for Behavioral Neurology What is the present parental concern? What is the present student concern FAMILY HISTORY MOTHER Name Approximate Height Approximate Weight Eye Color Blue Green Gray Handedness Right Left Ambidextrous Education Highest grade attained: Hazel Brown Employment / Profession Areas of Skill Areas of Weakness Physical health problems and surgeries (please list) Any history of a learning disorder?

18 Institute for Behavioral Neurology Any history of sleepiness? Any history of hyperactivity? Any history of emotional disorder? FATHER Name Approximate Height Approximate Weight Eye Color Blue Green Gray Handedness Right Left Ambidextrous Education Highest grade attained: Hazel Brown Employment / Profession Areas of Skill Areas of Weakness Physical health problems and surgeries (please list) Any history of a learning disorder? Any history of sleepiness? Any history of hyperactivity? Any history of emotional disorder?

19 Institute for Behavioral Neurology SIBLINGS Name Gender Male Female Approximate Height Approximate Weight Eye Color Blue Green Gray Hazel Handedness Right Left Ambidextrous Education Highest grade attained: Brown Employment / Profession Areas of Skill Areas of Weakness Physical health problems and surgeries (please list) Any history of a learning disorder? Any history of sleepiness? Any history of hyperactivity? Any history of emotional disorder?

20 Institute for Behavioral Neurology MATERNAL GRANDFATHER Name Approximate Height Approximate Weight Eye Color Blue Green Gray Handedness Right Left Ambidextrous Education Highest grade attained: Hazel Brown Employment Unskilled Labor Skilled Labor Homemaker Small Business Corp Executive Professional Other (specify) : Areas of Skill Areas of Weakness Physical health problems and surgeries (please list) Any history of a learning disorder? Any history of sleepiness? Any history of hyperactivity? Any history of emotional disorder?

21 Institute for Behavioral Neurology MATERNAL GRANDMOTHER Name Approximate Height Approximate Weight Eye Color Blue Green Gray Handedness Right Left Ambidextrous Education Highest grade attained: Hazel Brown Employment Unskilled Labor Skilled Labor Homemaker Small Business Corp Executive Professional Other (specify) : Areas of Skill Areas of Weakness Physical health problems and surgeries (please list) Any history of a learning disorder? Any history of sleepiness? Any history of hyperactivity? Any history of emotional disorder?

22 Institute for Behavioral Neurology PATERNAL GRANDFATHER Name Approximate Height Approximate Weight Eye Color Blue Green Gray Handedness Right Left Ambidextrous Education Highest grade attained: Hazel Brown Employment Unskilled Labor Skilled Labor Homemaker Small Business Corp Executive Professional Other (specify) : Areas of Skill Areas of Weakness Physical health problems and surgeries (please list) Any history of a learning disorder? Any history of sleepiness? Any history of hyperactivity? Any history of emotional disorder?

23 Institute for Behavioral Neurology PATERNAL GRANDMOTHER Name Approximate Height Approximate Weight Eye Color Blue Green Gray Handedness Right Left Ambidextrous Education Highest grade attained: Hazel Brown Employment Unskilled Labor Skilled Labor Homemaker Small Business Corp Executive Professional Other (specify) : Areas of Skill Areas of Weakness Physical health problems and surgeries (please list) Any history of a learning disorder? Any history of sleepiness? Any history of hyperactivity? Any history of emotional disorder?