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Questionaire
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What is the main reason for your visit?
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How long have you been suffering from this problem?
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Have you ever been treated from this problem?
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If yes, which ones?
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Are you allergic to any medication?
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If yes, which?
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Are you taking any of the following
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Do you drink alcohol?
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If yes, how often?
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Do you smoke tobacco?
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If yes, how many?
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Have you ever had any surgeries?
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If yes, what kind & when?
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Have you ever been hospitalized?
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If yes, why?
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Have you had any radiology imaging (e.g. MRI, CT, XRay, Ultrasound)
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If yes, what kind?
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Neurological:
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Heart and Circulation
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Eyes
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Muscles, Bones, and Joints
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FOR WOMEN ONLY:
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Are you pregnant?
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Date of last menstrual period:
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Have you experienced any of these symptoms in the LAST SIX MONTHS?
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General
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Stomach and Bowels
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Head
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Eyes
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Bladder and Kidney
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Lungs
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Muscles, Bones, Joints
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Neurological:
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Heart and Circulation
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Psychological
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Any other information/details we should know?
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List of Medications
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Name
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Dosage/ Frequency
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Name
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Dosage/ Frequency
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Name
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Dosage/ Frequency
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Name
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Dosage/ Frequency
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Name
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Dosage/ Frequency
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Name
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Dosage/ Frequency
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Name
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Dosage/ Frequency
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Name
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Dosage/ Frequency
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Name
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Dosage/ Frequency
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Name
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Dosage/ Frequency
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Name
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Dosage/ Frequency
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Name
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Dosage/ Frequency
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Name
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Dosage/ Frequency
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Name
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Dosage/ Frequency
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Name
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Dosage/ Frequency
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Name
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Dosage/ Frequency
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Name
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Dosage/ Frequency
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Name
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Dosage/ Frequency
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Pharmacy
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Pharmacy Name:
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Phone number
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Address
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City
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State
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Zip Code
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Authorization of Use & Disclosure of Protected Health Information
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Patient Name
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Date of Birth
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Address
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Home Phone
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Cell Phone
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I, the above named patient, authorize Interventional Neuro Associates to use or disclose my PHI, as follows:
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1. The type and amount that I am authorizing to be used or disclosed is: (please initial the appropriate items)
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Medical/ surgical claims information
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History and physical exam
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Consultation report/ notes
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Surgical operative reports
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Lab reports
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X-ray/ MRI/ MRA reports
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Leave detailed messages on the home phone listed above
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Leave detailed messages on the cell phone listed above
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Leave detailed text messages on the cell phone listed above
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Other/ Comments:
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