PATIENT INFORMATION SHEET

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ALAMO NEUROSURGICAL INSTITUTE 414 W SUNSET, SUITE 205 SAN ANTONIO, TEXAS 78209 WWW.ANI-ONLINE.COM OFF: 210.564.8300 FAX: 210.564.8399 PATIENT INFORMATION SHEET Patient Name (Last, First, Mi): SSN: Street Address: City: State: Zip: Telephone (home): (cell): E-mail Address: Marital Status: Spouse Name: DOB: Parent (If under 18 years)/guardian Name: Driver s License Number: ETHNICITY RACE LANGUAGE Hispanic or Latino American Indian or Alaska Native English Non-Hispanic or Latino Asian French Declined Black or African American Indian Native Hawaiian or Pacific Islander Japanese Caucasian Spanish Declined Declined Employer Name: Supervisor Contact Name: Phone # Emergency Contact: Phone # Referring Doctor: Phone # Primary Care Physician: Phone #

MEDICAL HISTORY FAMILY HISTORY Do you have any MEDICAL HISTORY that runs in your family? (Parents/Siblings/Extended Family) YES NO CANCER Father Mother Brother/Sister Ext. Family DIABETES Father Mother Brother/Sister Ext. Family HEART ATTACH Father Mother Brother/Sister Ext. Family HIGH CHOLESTEROL Father Mother Brother/Sister Ext. Family HYPERTENSION Father Mother Brother/Sister Ext. Family STROKE Father Mother Brother/Sister Ext. Family THYROID Father Mother Brother/Sister Ext. Family Father (Other) Mother Brother/Sister Ext. Family PATIENT HISTORY AGE: HEIGHT: WEIGHT: Do you currently use TOBACCO? YES NO If yes how many packs per day? How many years of use? Do you have a previous use of TOBACCO? YES NO If yes how many packs per day? How many years of use? Do you consume ALCOHOL? YES NO Frequency: Daily Weekly Monthly How many consumed? Are you at risk for AIDS? YES NO Have you ever had a BLOOD TRANSFUSION? YES NO If yes what year? Please list ALL MEDICATIONS that you are ALLERGIC to (include latex or other allergies.) Please list ALL MEDICATIONS AND DOSAGE that you are currently taking (including aspirin and ibuprofen.) Please list ALL CURRENT and PAST Medical History (examples: COPD, diabetes, high blood pressure, high cholesterol.) Please list ALL PREVIOUS SURGICAL PROCEDURES and DATES (please list)

REVIEW OF SYSTEMS PLEASE CHECK ANY OF THE FOLLOWING BOXES THAT APPLY TO YOUR CURRENT SYMPTOMS GENERAL: Anorexia Appetite Loss Chills Dietary Changes Excessive Crying Fatigue Fever Medication Changes Night Sweats Obesity Weight Gain greater than 10lbs Weight Loss greater than 10lbs SKIN: Bruising Dryness Excessive Sweating New Lesions Rash Skin Color Changes NECK: Neck Mass Neck Pain Neck Stiffness Swollen Glands HEENT: Blurred Vision Headache Head Injury Color Blindness Decreased Night Vision Double Vision Excessive Tearing Eye Pain Eye Redness Visual Disturbances Visual Loss Hearing Loss Deafness Decreased Hearing Ear Discharge Ear Infection Ear Pain Earache Ringing in Ears Tinnitus Spinning Sensation Vertigo Nose Bleed Frequent Colds Nasal Congestion Rhinitis Seasonal Allergies Sinus Pain Bleeding Gums Hoarseness Oral Ulcers Sore Throat Voice Changes RESPIRATORY: Chronic Cough Cough Decrease Exercise Tolerance Snoring Difficulty Breathing Dyspnea Hemoptysis Sputum Production Wheezing CARDIOVASCULAR: Chest Pain Calf cramps Difficultly Breathing on Exertion Difficulty Breathing Lying Down Fainting/Blacking Out Edema (swelling) Irregular Heart Beat Abnormal Blood Pressure Elevated Blood Pressure Hypertension Night Cramps Palpitations Rapid Heart Beat Leg Pain and or Swelling Phlebitis Shortness of Breath Swelling of Extremities

GASTROINTESTINAL: Abdominal Mass Abdominal Pain Black, Tarry Stool Blood in Stool Change in Bowel Movement Constipation Diarrhea Difficulty Swallowing Dysphagia Food Intolerance Gas Hematemesis Heartburn Indigestion Jaundice Nausea Rectal Bleeding Vomiting Vomiting Blood MUSCULOSKELETAL: Arm Pain Backache Back Pain Calf Pain Claudication Decreased Range of Motion Fasciculations Joint Pain Joint Redness Joint Stiffness Joint Swelling Muscle Atrophy Muscle Cramps Muscle Pain Muscle Weakness Myalgia Swelling of Extremities NEUROLOGICAL: Auras Decreased Memory Difficulty Speaking Dizziness Dysarthria Dysesthesia Fasciculations Fainting Focal Neurological Symptoms Incoordination Loss of Consciousness Paresthesia/Numbness Seizures Syncope Spinning Sensation Stroke Tremor Unusual Sensation Unsteadiness Vertigo Visual Changes Weakness Weakness in Extremities PSYCHIATRIC: Anxiety Change in Sleep Patterns Delusions Depression Early Awakening Fearful Hallucinations Hypersomnia Inability to Concentrate Mood Changes Insomnia Panic Attacks ENDOCRINE: Appetite Changes Cold Intolerance Excessive Thirst Excessive Urination Hair Changes Heat Intolerance Hot Flashes Libido Change Sexual Dysfunction Thyroid Problems HEMATOLOGY: Abnormal Bleeding Anemia Blood Clots Easy Bruising Enlarges Lymph Notes Epitasis Nose Bleed Petechiae Prolong Bleeding Spontaneous Bleeding

CURRENT AND PREVIOUS NON-SURGICAL TREATMENT Please fill in any of the below treatments you have undergone for you current symptoms/injury. CHIROPRACTIC TREATMENT: YES NO Treating Physician Name: PHYSICAL THERAPY: YES NO Treating Physician Name: PAIN MANAGEMENT: YES NO Treating Physician Name: EMG/NCV (nerve) STUDY: YES NO Ordering Physician Name: OTHER STUDIES: Ordering Physician Name:

PAIN DRAWING AND PAIN RATING SCALE Using the drawing and symbols below. mark the appropriate areas of the body that you are CURRENTLY EXPERIENCING PAIN. Multiple symbols may be used in the same area as the symbols indicate the symptom type. SYMBOLS (describes type of pain) ACHE BURNING NUMBNESS PINS AND NEEDLES STABBING AAAA VVVV FRONT BACK Using the scale below rate your PAIN LEVEL by circling the appropriate number 1----------2----------3----------4----------5----------6----------7----------8----------9----------10 slight mild medium severe excruciating

ALAMO NEUROSURGICAL INSTITUTE 414 W SUNSET, SUITE 205 SAN ANTONIO, TEXAS 78209 WWW.ANI-ONLINE.COM OFF: 210.564.8300 FAX: 210.564.8399 MEDICAL RECORDS AUTHORIZATION AND RELEASE FORM I hereby authorize ALAMO NEUROSURGICAL INSTITUTE, PA and staff permission to obtain and use any and all medical records necessary for the purpose of my treatment. Patient Name Date of Birth Social Security # Address Telephone # Signature Date

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