NEUROLOGICAL SURGERY, P.C.
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1 NEUROLOGICAL SURGERY, P.C. PATIENT INFORMATION Name Date of Birth Age Address City Sate NY Zip Home ( ) - Cell ( ) - Work ( ) - Ext: Address _ Sex M F Soc. Sec. #: / / Single Married Widowed Separated Divorced Occupation Employer Employer s Address Referred By Phone: ( ) Address Primary Care Physician Phone: ( ) Address: _ Preferred Pharmacy Name Phone Fax Pharmacy Address: Emergency Contact/Relationship Phone: INSURANCE INFORMATION Primary Insurance Policy Holder s Name ID# Policy Holder s Birth Date Policy Holder s SS# Secondary Insurance Relationship Policy Holder s Name ID# Birth Date SS#: Group # WORKER S COMPENSATION or NO FAULT: please circle one Insurance Company OF ACCIDENT Address Policy Number Carrier Case # Case Manager Phone: ( ) Ext:
2 MAKE SURE TO ANSWER ALL QUESTIONS. SIGN AND EACH PLACE INDICATED. THANK YOU. I. What is the main complaint for which you are coming to this office? II. What is the history of your present illness? (If you require additional space, please use back of page.) a. When did the problem start? b. Where is the problem located? c. Has it become worse? better? same? d. If you have pain, does the pain travel? where to? e. Is the problem constant? f. If the problem is on and off, is it daily? weekly? monthly? other? g. What, if anything, makes it better? h. What, if anything makes it worse? i. What treatments have you had for this problem? j. Are there any other problems associated with your main problem? headache vision speech numbness dizziness hearing pain weakness III. FAMILY HISTORY A. Check the condition, and which family member has the condition (i.e. mother, father, brother, sister, son, daughter, etc.) Arthritis Allergy Gout Cancer Diabetes Jaundice Psychosis Ulcer Coronary Disease Epilepsy Rheumatic Heart Disease Hypertension Gall Bladder Stones Tuberculosis Bleeding Tendency Thyroid Nervous Breakdown Kidney Stones Kidney Disease Leukemia or Lymphoma B. Mother Living Died at age cause C. Father Living Died at age cause 2
3 MAKE SURE TO ANSWER ALL QUESTIONS. SIGN AND EACH PLACE INDICATED. THANK YOU. IV. HABITS w Alcohol w Tobacco AMOUNT HOW LONG WHEN CHANGED Height: Weight: lbs Gain Loss Sleep hours Eating Habits: Good Poor V. CURRENT MEDICATIONS (attach a list or write below with does and times per day) MEDICATION DOSE TIMES PER DAY MEDICATION DOSE TIMES PER DAY VI. SOCIAL HISTORY Marital Status: Single Married Divorced Widowed how long? Present Occupation: How long? Prior Work: Exposure to Occupational Disease: Yes No When Travel _ VII. PREVIOUS HEALTH AND ILLNESS A. General Health 1. Recent examinations and hospitalizations: 2. Past medical illnesses: 3. Past Surgeries: 4. Radiation Therapy: 5. Last Tetanus Booster: 6. Transfusions: date: amount: reactions: 7. Have you ever had a Tumor or Cancer? Where and when? 3
4 MAKE SURE TO ANSWER ALL QUESTIONS. SIGN AND EACH PLACE INDICATED. THANK YOU. VII. PREVIOUS HEALTH AND ILLNESS (continued) B. Review of Systems (check and explain in # 11) 1. ALLERGIES: Asthma Food Hayfever Urticaria Inhalants Penicillin Drugs AMBIEN 2. HEAD: Headache Visual Disturbance Dental Disease Sinusitis Earache Bleeding Gums Head Injury Tinnitus Upper Respiratory Infection Hearing Disturbance Nose Bleed 3. RESPIRATORY TRACT: Pleurisy Sputum Hoarse Wheezing Hiccups Pneumonia Bronchitis TB Chronic Cough Spitting up Blood Other Last Chest X-Ray 4. CARDIAC: Angina Hypertension (high blood pressure) Arrhythmia Cyanosis Heart Murmur Palpitations Edema Dyspnea (difficulty breathing) Enlarged Heart Nocturnal Dyspnea (difficulty breathing at night) NONE Last EKG Special Diagnostic Tests Results 5. GI (Gastro-intestinal): Dysphagia (difficulty swallowing) Anorexia Bowel Habit Change Nausea Cramps Eructation (belching) Constipation Jaundice Hemorrhoids Heartburn Diarrhea Abdominal Pain Indigestion Hernia Hematemesis (vomiting blood) Black or Bloody Stool Other: 6. GU (Genito-urinary): a. Male/female Dysuria (difficulty urinating) Hematuria (blood in urine) Facial Edema (swelling) VD (venereal disease) Nocturia (urinating at night) Urinary retention Frequency Back Pain Stones Other: b. Female Menarche Menses Regular LMP Abnormal Bleeding Last Pap Smear Post-menopausal bleeding Number of pregnancies Abortions Number of children Other: 4
5 MAKE SURE TO ANSWER ALL QUESTIONS. SIGN AND EACH PLACE INDICATED. THANK YOU. 7. Neuro-Muscular: Dizziness Abnormal Gait Memory Problems Syncope Unconsciousness Weak Spell Vertigo Paresthesias (abnormal sensations) Joint Pain Convulsions Tremor Arthritis Other: 8. Emotional: Personality Change Nervous Breakdown Depressed Psychiatric Treatment Other: 9. Do you have DIABETES? PACEMAKER? DEFIBRILLATOR? 10. Symptoms or Diseases not listed: 11. Explanation of checked items: E Date: Patients Signature 5
Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?
PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:
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PATIENT INFORMATION FORM (WOMEN ONLY)
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MEDICAL DATA SHEET For Patients 18 years of age and older
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City State Zip Code. Ethnic Background: Caucasian African-American Asian Hispanic Native American. Previous. Hobbies/Leisure activities:,,,
History # UPIN # (Please leave blank) Name: First M.I. Last Address: Street (Apt #) City State Zip Code Phone number: ( ) ( ) Home Business Birth Date: / / Day-Month-Year Gender: M F Marital status: (Maiden
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MEDICAL DATA SHEET For Patients 18 years of age and older
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Patient History Form
Patient Personal Information Name: Date: Age: Occupation: Employer's name: Briefly describe your daily activities at work: Sex: male female Marital Status: single married divorced widowed Spouse's name:
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PATIENT HEALTH HISTORY
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CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:
CASE HISTORY Account #: Please complete this form using your keyboard, then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment.
PATIENT DATA SHEET GENERAL INFORMATION DATE ( ) ( ) ( ) HOME PHONE WORK PHONE CELL PHONE
PATIENT DATA SHEET GENERAL INFORMATION / / DATE LAST NAME FIRST NAME MIDDLE INITIAL ADDRESS CITY STATE ZIP CODE ( ) ( ) ( ) HOME PHONE WORK PHONE CELL PHONE EMAIL ADDRESS SEX MALE FEMALE (PLEASE CIRCLE)
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Primary Chief Complaint 1. Location 2. When did this begin? 3. How did this begin?
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MEDICAL DATA SHEET For Patients 18 years of age and older
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Health History Questionnaire Date: / /.
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Patient Interview Form
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Inner Balance Acupuncture
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