NEW PATIENT REGISTRATION PLEASE COMPLETE ALL ITEMS ON EACH PAGE Date Name (Last, First, M.I.) Address City State Zip Code Phone ( ) Work ( ) Cell ( ) Date of Birth Age Marital Status SSN Employer Employer s Address Accident (Auto/Other) Worker s Comp Date of Injury Referring Physician Primary Care Physician Spouse s Name SSN Spouse s Employer Phone ( ) Nearest Relative Not Living With You Relationship Phone ( ) Work ( ) Cell ( ) Emergency Contact Information Name Relationship Phone ( ) Work ( ) Cell ( )
METHOD OF PAYMENT Co-payments are due at the time services are rendered. We will bill your insurance company for your office visits and other charges. We do not bill insurance companies for office visits if we are not a provider for your insurance plan. Please indicate your method of payment: Cash Check Credit Card Worker s Comp Medicare Insurance Company: Policy Number Name of Insured Relationship to Patient INSURANCE AUTHORIZATION AND ASSIGNMENT I authorize payment of medical benefits for any services rendered to me by Dr. Philip Henkin, Dr. Tien V. Le, Taylor Lawton, PA-C, or Adam Suchecki, PA-C to be paid directly to NeuroSpine Center. I authorize the release of any medical information necessary to process all claims and request payment for services rendered. I understand that I am responsible for any amount not covered by my insurance company. I direct my insurance carrier that a photocopy of this authorization shall be considered a valid assignment of benefits in lieu of the original. It is mandatory that you tell our office if you know that another party is responsible for paying for your treatment. Section 112B of the Social Security Act and 31 USC 3801-3812 provide penalties for withholding this information. Patient Signature
MEDICAL RECORDS RELEASE I hereby authorize to release information pertaining to my examination, treatment, diagnosis or prognosis to: Philip Henkin, M.D. Tien V. Le, M.D. 10740 Palm River Rd, Tampa, FL 33619 Office: (813) 651-3300 Fax: (813) 651-4455 A photocopy of this authorization shall be considered a valid release in lieu of the original. Patient Printed Name Patient Signature 11-POINT REVIEW OF SYSTEMS
Please check appropriate blank below if you have had any of the symptoms in the last 1 month. 1. Constitutional: Generalized weakness Chronic fatigue Fever Chills Major weight gain 2. Neurological: Headache Confusion Memory difficulties Speech difficulties Focal weakness Incoordination Gait Imbalance Focal numbness Blackouts Seizure Tremors 3. Psychiatric: Depression Anxiety Nervousness Hopelessness Suicidal/Homicidal ideations 4. Cardiovascular: Chest pain Palpitations Decreased exercise tolerance Dizziness Chest congestion 5. Respiratory: Shortness of breath Difficulty breathing Wheezing Bronchitis Chronic cough Coughing blood Difficulty breathing while lying flat Urinary frequency Urinary urgency Pain on urination Blood in urine 8. Eyes: Blurred vision Double vision Decreased peripheral vision Blind spots Flashes of light Drooping of eyelid Excessive tearing 9. Ears, Nose, Mouth & Throat: Decreased hearing Earaches Ringing in ears Ear infections/discharge Decreased sense of smell Nosebleeds Chronic sinusitis Recent major dental work Difficulty swallowing Hoarseness Bleeding gums 10. Endocrine: Heat or cold intolerance Excessive sweating Excessive urination Excessive thirst 11. Musculoskeletal: Muscle pain Joint pains Chronic back pain Chronic neck pain Joint stiffness and restricted range of motion Joint warmth or redness 6. Gastrointestinal: Abdominal pain Nausea Vomiting Constipation Diarrhea Heartburn Change in bowel habits Trouble swallowing Bloody or black, tarry stools Fecal incontinence 7. Genitourinary: Urinary incontinence
PRESENT ILLNESS Where are your symptoms? (e.g. Neck, Arms, Back, Legs, Right vs. Left, etc.) How long have you had your symptoms? What have you tried to relieve your current symptoms? (Circle all that apply) Pain Management - PT - Chiropractic - Anti-inflammatories - Narcotics - Neuromodulators - Muscle Relaxants - Heat/Cold - Inversion table - Other Please circle your pain severity TODAY. (0 = No pain & 10 = Worst pain imaginable) 0---1---2---3---4---5---6---7---8---9---10 Indicate all that describes your pain: Sharp/Stabbing - Burning - Aching Cramping - Tingling - Numbing When does your pain occur: Constantly - Intermittently - w/ Positional change MEDICAL & SURGICAL HISTORY What MEDICAL conditions have you been diagnosed with? What SURGICAL procedures have you undergone and when? SOCIAL HISTORY Are you a current or past smoker? Yes or No If yes, How many packs per day? If yes, How many years have you smoked for? Do you consume alcohol? Yes or No If yes, what type and how much per month?_ Height: Weight: Estimated weight at 20 years of age:
FAMILY HISTORY If any of your family members have had the following conditions, please list their relationship and age. Cancer, Heart Attack, High Blood Pressure, Stroke, Epilepsy or Seizures, Migraine Headaches, Diabetes, Bleeding disorders CURRENT MEDICATIONS (Include Dosage) DRUG ALLERGIES