* = Required Information

REGISTRATION FORM

PATIENT INFORMATION

Name: * SSN: * Gender: * MaleFemale

First Name        Last Name          Middle Name

Birthdate: * Marital Status: SingleMarriedWidowedSeparatedDivorced

Language:

Race: AsianAmerican IndianWhiteBlackUnknown Ethnicity: HispanicNon-HispanicUnknown

Address: City: Zipcode:

Phone: (Home): * (Work): * (Cell): *

Email:

Emergency Contact Name/Ph:

Referring Physician's Name + Phone: *

Pharmacy Name: Address

Pharmacy Phone: Pharmacy Fax:

Do you want to enroll in Online Access for Health Records? YesNo

PRIMARY INSURANCE

Are you Self Pay? YesNo         If Yes, Skip this box.

Insurance Company: * Phone:

Policy #: * Group #: *

Subscriber Full Name: * Relationship to Patient: *

Birthdate: *

SSSN: Address if different from Patient:

Phone if different: (Home): (Work): (Cell):

Medicare #: Medicaid #:

Do you have additional Secondary Insurance?: YesNo If Yes, Secondary Insurance Company:

Policy #: Group #:

Subscriber Full Name: Relationship to Patient:

Birthdate:

I hereby assign all medical benefits including major benefits to which I am entitled for medical services rendered to myself or my dependent to Kiran P Shah, MDPA and Neurology & Sleep Clinic. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance company. I hereby authorize said assignee to release all information necessary to secure payment on my behalf.

Signature of Patient or Parent if Minor * Relationship * Date *

HISTORY FORM
Name * Height: Ft.   in.     Neck Girth: in.   Handed: Right Left Occupation: Education: High school GED College PhD/Masters
What is the reason for your visit? When did symptoms start? Does it occur daily, weekly, monthly or randomly? What is the location of the symptoms? Does it involve any other body part? What makes it worse? What makes it better? How do you rate your symptoms? (0- none, 10- worst ever) Related to work injury or automobile accident How do the symptoms affect your daily activities at home and work? Have you tried any medications (over the counter or prescribed)? Please provide results and location of recent CT, MRI, Blood work, EMG, EEG, Sleep Study: Do you have any of the following symptoms at PRESENT TIME: Headache Visual change Nausea/ Vomiting Dizziness/ Vertigo Difficulty swallowing Difficulty speaking Memory problems Tremors Hearing problems Seizures Falls Passing out Snoring Daytime sleepiness Fatigue Restless legs Muscle Stiffness Hand/Arm pain Neck pain Foot/ leg pain Low back pain Hand weakness Tingling/ Numbness Difficulty walking Incontinence
Past Medical History: Hypertension Diabetes High Cholesterol Sinus disease Heart disease/ CHF COPD/ Emphysema Stroke Brain tumor/ Aneurysm Bleeding disorder Cancer Stomach Ulcer Depression/ Anxiety Liver disease Kidney disease Hypothyroidism Vitamin Deficiency Anemia Other
Past Surgical History: (Please list all surgeries and dates): Brain Neck Back Heart Carotid Tonsils Knee DBS VNS Others
Have you had any recent accidents or injuries? Have you had any recent hospitalization?
Family History: (State the health information of the following family members) Parents: Siblings: Children: Grand-Parents: Extended Family: Are you adopted : Yes No Does any hereditary disorder run in your family?
Social History: Tobacco: Never Smoked Former Smoker Quit Date: Current every day Smoker Alcohol: Do not Drink Occasional/Social Drinker Heavy Drinker Used to drink Illicit Drugs: Do you take drugs? Yes No Which ones? How often: Used to take in past: Caffeine: Coffee Tea Soda How many and how often? Where do you live? Private residence Assisted Living Nursing Home- Who do you live with? Marital Status: Single Married Divorced Widower Do you exercise regularly? Yes No How often per week: Spouse's job:
Allergies: (Medications & Food):
Medications: (List all medications � prescribed and over the counter- with dosage) Do you take Aspirin or other Anti-platelet medication? Yes No Since how long
Review of system: Please choose any problems that are present at present? Fever chills night sweats Weight gain weight loss Bleeding bruising Hearing problems Vomiting Double vision blurry vision Palpitation Chest pain Shortness of breath Constipation Diarrhea Nausea Urinary incontinence Anxiety Depression Skin Rash Sexual complaint Joint Pains
Epworth Sleepiness Scale: How likely are you to doze off or fall asleep in the following situations? 0- would never doze, 1- Slight chance of dozing, 2- Moderate chance of dozing, 3- High chance of dozing. Sitting and Reading 0 1 2 3 Watching Television 0 1 2 3 Sitting inactive in a public place (theatre) 0 1 2 3 As a car passenger for an hour without break 0 1 2 3 Lying down to rest in the afternoon 0 1 2 3 Sitting and talking to someone 0 1 2 3 Sitting quietly after lunch without alcohol 0 1 2 3 In a car, while stopping for few minutes in traffic 0 1 2 3
Sleep Environment: What time do you sleep on weekdays? What time do you sleep on weekends? What time do you wake up on weekdays? What time do you wake up on weekends? Average number of awakenings during sleep: 0 1 2 3 Do you read in Bed? 0 1 2 3 Do you carry work to bed? 0 1 2 3 Do you watch TV in bed? 0 1 2 3 Does your bed partner have sleep problems? 0 1 2 3 Do you nap in daytime, If yes, how long? 0 1 2 3 Trouble falling asleep: 0 1 2 3 Trouble staying asleep: 0 1 2 3 Snoring: 0 1 2 3 Your Breathing stops at night: 0 1 2 3 Wakes up to pass urine at night: 0 1 2 3 Have Heartburns at night: 0 1 2 3 Have Leg kicking at night: 0 1 2 3 Have Sweating at night: 0 1 2 3 Teeth grinding at night: 0 1 2 3 Inability to move while falling asleep: 0 1 2 3 Have Unusual vision at sleep onset: 0 1 2 3 Feel Groggy/tired on awakening: 0 1 2 3 Have Morning headaches on awakening: 0 1 2 3 Wake up with dry mouth: 0 1 2 3 Nightmares: 0 1 2 3 Have Seizures during sleep: 0 1 2 3 Have Daytime sleepiness: 0 1 2 3 Have Daytime fatigue: 0 1 2 3 Fights sleep while driving: 0 1 2 3 Have Loss of strength/falls when startled: 0 1 2 3 Have Memory problems: 0 1 2 3 Had motor vehicle accident due to sleepiness: 0 1 2 3 History of narrowed airway or enlargement of tonsils/adenoids: Yes No History of Tonsillectomy/Adenoidectomy: Yes No Prolong sitting at work or home or Lack of regular exercise: Yes No Sleep Study in past: Yes No CPAP or BiPaP tried in past: Yes No *I have reviewed and completed all 3 pages of History Form today.
Patient or Guardian Signature Date
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