Welcome to the Kentucky Neuroscience Institute at the University of Kentucky!

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Transcription:

Welcome to the Kentucky Neuroscience Institute at the University of Kentucky! The Kentucky Neuroscience Institute is on the first floor of the Kentucky Clinic. The address is 740 South Limestone Street, Lexington, Kentucky. Watch for signs directing you to the Kentucky Clinic parking garage. Your appointment has been especially reserved for you. If you are late we may have to reschedule your appointment so that other patients won t have to wait. If you need to cancel your appointment or schedule your appointment for a different time, please call us as soon as possible at (859) 323-1334. If you do not call to cancel your appointment and don t show up, we may require a new referral. PLEASE DO THE FOLLOWING: 1. Be sure to bring your most updated insurance card with you. Your insurance company requires that we collect the co-pay on the day of your appointment, so please bring that, too. We can accept cash, check, or credit/debit cards. If you do not currently have insurance, we require a $100.00 deposit on the day of the appointment. We will also help you to complete paperwork that may make you eligible for financial assistance, reducing your medical costs at UK. 2. Fill out the enclosed medical history forms prior to your visit. These are essential to guide the doctors in diagnosis and treatment of your condition. 3. If you have recently had an MRI, CT scan, or other imaging done at an outside hospital, you must bring these with you to your appointment. Do not rely upon your doctor s office to send these. If you do not bring the images, we may have to reschedule your appointment. If you have any other questions, please call us at (859) 323-5661. We are looking forward to your visit. Sincerely, Michael Dobbs, M.D. Medical Director, KNI Clinic Kentucky Neuroscience Institute Clinic Departments of Neurology & Neurosurgery 740 South Limestone, Suite B101 Lexington, Kentucky 40536-0284 Tel: (859) 323-5661 Fax: (859) 323-6411

Dr. Phillip Tibbs Dr. Thomas Pittman PATIENT NAME Dr. Karin Swartz Dr. Greg Wheeler DATE OF BIRTH Dr. Justin Fraser Dr. Craig Van horne (Addressograph) Who referred you to the Neurosurgery Clinic? Doctor City Phone Who is your Family Physician? Doctor City Phone Briefly describe your problem: What is the date when your problem started? or other type of accident/injury? Yes or No If "Yes", Please describe briefly: Is your problem due to a motor vehicle accident, work injury, What type of work do you do? What was the last day you worked? PERSONAL MEDICAL HISTORY Have you had any chronic / serious illnesses? Yes or No If "Yes", Please explain: List any operations you have undergone: Please List all your Current Medications, their dosage, and how often you take them in the colums provided below: Medication mg Frequency Medication mg Frequency List any medications you are allergic to: Have you sustained any disabling / serious injuries? Yes or No If "Yes", Please List: Do you smoke? Yes or No If so, How many years? How many packs per day? How many children do you have? FAMILY MEDICAL HISTORY If anyone in your immediate family has ever had any of the following, please mark the box accordingly: 1. Heart Attack 2. Cancer 3. Hypertension 4. Stroke 5. Back Problems Mother Father Grandparent Brother / Sister

Please indicate with an if you have a new problem, prior existing condition, or if you never had the condition from the list below. CONSTITUTIONAL NEW PRIOR NEVER 1. Weight Gain? 2. Weight Loss? 3. Hair Loss? EYES 1. Double vision? 2. Eye Pain? 3. Vision change? EARS, NOSE, & THROAT 1. Hearing Loss? 2. Sore Throat? CARDIOVASCULAR 1. Heart murmur? 2. High blood pressure? 3. Treatment for High blood pressure? 4. Chest pain after exertion 5. Heart Attack? 6. Abnormal electrocardiogram? 7. Rapid pulse / heart beat? 8. Irregular pulse? 9. Leg cramps after walking? RESPIRATORY 1. Coughing up blood? 2. Chest Pain? 3. Shortness of Breath? GASTROINTESTINAL 1. Abdominal pain? 2. Black bowel movement? GENITOURINARY 1. (Male) Prostate Problems? 2. (Male) Erectile problems? 3. (Male or Female) Blood in Urine? 4. (Male or Female) Bladder Infection? 5.(Female) Date of last Pap Smear: 6. (Female) Date of last Mammogram Results: Results: On the two figures shown Please indicate the areas that are troubling you most. MUSCULOSKELETAL 1. Sciatica? 2. Back / Neck pain? SKIN (INTEGUMENTARY) 1. New skin growths? 2. Growths that change in size? NEUROLOGICAL 1. Frequent headaches? 2. Migraine headaches? 3. Loss of vision? 4. Weakness or Pain in arms / legs? 5. Convulsions? 6. Stroke? PSYCHOLOGICAL 1. Depression? 2. Mood swings? ENDOCRINOLOGY 1. Diabetes? 2. Thyroid problems? HEMATOLOGY 1. Anemia? 2. Clotting Factor? ALLERGY 1. Food? 2. Drug? 3. Environmental? DATE: DATE: Patient Signature: Physician Signature:

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