Please do not hesitate to reach out to our team with any questions regarding your New Patient appointment. We look forward to meeting you soon.
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- Alaina Thompson
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1 We are excited about your upcoming appointment with Texas Alzheimer s & Memory Disorders. Please find the enclosed ew Patient packet that we are requesting be completed prior to your visit with us. Appointment Date: Time: Please arrive 20 minutes prior to your appointment time and expect your appointment to last about an hour. Our Office Is Located at: 8198 Walnut Hill Lane (Texas Health Presbyterian Dallas) Suite 100 Jackson Building Dallas Texas ** Jackson Building is located behind the Margot Perot Building Contact umbers: Phone: Fax: Please do not hesitate to reach out to our team with any questions regarding your ew Patient appointment. We look forward to meeting you soon. Sincerely, Texas Alzheimer s & Memory Disorders Team
2 Friendly Reminders and Requests for your Initial visit: - Insurance Information: Please bring your Insurance ID and Photo ID. We cannot see you without proper identification. *If you have any questions regarding your insurance coverage, please contact your insurance carrier prior to the visit - Family Members: If possible, please have a family member or close friend join you for your appointment. We request this in order to obtain additional information regarding your symptoms. - Completed Patient History Questionnaire: Please ensure you complete to the best of your ability and list ALL current medications and vitamins; including the dosage. - Early Arrival: We request you arrive 20 minutes prior to your scheduled appointment time. Allow extra time for traffic and parking- we do validate parking tickets. If you are 15 minutes late for your appointment; you will be rescheduled. What to Expect: We will review symptoms and health history with you and your family, and perform an evaluation comprised of various neurological tests. Based on the findings; we may recommend additional testing. This may include blood work, brain imaging, neuropsychological testing and/ or additional consultants or therapies. Please note, because disturbances in cognitive functioning can be caused by multiple factors, a diagnosis may not be available during your initial visit. Thank you! Texas Alzheimer s & Memory Disorders Team
3 PATIET HISTOR QUESTIOARE ame: Birthdate: Age: Describe the problem you are having: When did it start? (year and month if possible) Did it start (circle one) Suddenly Gradually over years Gradually over weeks/months Over the past year are symptoms (circle one) Worsening Getting Better Staying the same Allergies: Have you experienced any of the following symptoms? Symptom Difficulties finding words Lose/ Misplace Things Repeat conversations/questions Get lost in a familiar Area Easily Distracted Disorganized Problems paying attention Memory Loss/ Forgetfulness Anxiety Depression Problems with Judgement Fever/Chills Unexplained weight Loss Change in appetite Rash Low back pain Blood clots in legs or lungs Skin of hair changes Headaches o ears Ago Past Month Symptom Joint Pains Smell or Taste Problems Loss of Vision Double Vision Loss of Hearing Slurred Speech Difficulty Breathing Chest Pain Palpitations Constipation Urinary Urgency or Hesitancy Bowel or Bladder accidents Urinary Tract Infections umbness in arms and legs Weakness in arms and legs Trouble Walking Frequent Falls Persistent Dizziness Sleepiness Trouble Sleeping o ears Ago Past Month
4 Current Medications (please include over the counter medications) MEDICATIO AME Dose (mg/day) For how long? What is this medication for? Pharmacy ame: Phone: Fax: Primary Care Doctor: Phone: Fax: eurologist: Phone: Fax: Cardiologist: Phone: Fax: Oncologist: Phone: Fax: Psychologist: Phone: Fax: Social History: Relationship status: Single (never married) Married Civil Union Domestic Partnership Widowed Divorced Separated Who do you live with? Alone Spouse Child(ren) Other: Where do you live? Apartment Condo House Other: How long? How do you spend your free time? Who can you call on for social support (for help, when you need to talk, etc)? Do you have a Power of Attorney for Healthcare? es, ame: Is this evaluation being requested by an attorney or for legal purposed? ES O
5 Family History: Does anyone in your family have a history of memory problems, dementia, or other neurological conditions? o ES es, Specify: Any history of Alzheimer s disease in your family? o ES Confirmed by autopsy? Other family history of medical/neurological / psychiatric problems? Family Member Living? Age now or at death Cause of death List any medical/neurological / psychiatric problems (e.g. high blood pressure) Mother Father Brothers/Sisters (list) Children, biological (list) Previous Medical, eurologic, Psychiatric History: Please check ( ) each of the following that you have now or have had in the past Medical Since Since Since Kidney Disease HIV AIDS Anemia Chronic Pain Exposure to Toxins Asthma Diabetes Sexual Dysfunction Arthritis Cancer/Type Stomach Problems High Cholesterol Lung Disease Heart Disease Vascular Disease High Blood Pressure Thyroid Disorder Other
6 eurological Since Since Since Alzheimer s ALS Encephalitis Head Injury Multiple Sclerosis Huntingon s disease Meningitis Migraines Movement Disorders Parkinson s Seizures Sleep Disorders Stroke Syphilis Psychiatric Since Since Alcohol Dependency Anxiety Disorder Eating Disorder Depression Drug Dependency Manic-Depressive (Bipolar) Illness Other Substance Use: Do you currently drink alcohol? O ES If yes, how much? Since when? Have you ever used alcohol regularly in the past? O ES If yes, how much? Do you currently use tobacco? O ES If yes, how much? Since when? Have you ever smoked or used tobacco regularly in the past? O ES If yes, how much? Do you currently or have you ever used other (recreational) drugs? O ES If yes, type?
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PRE-VISIT QUESTIONNAIRE FOR NEW PATIENTS
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MEDICAL HISTORY RECORD
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SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET
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HD CLINIC MEDICAL HISTORY FORM
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PULMONARY CARE OF CENTRAL FLORIDA, P.A. Date: / /
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