Annapolis Neurology Associates

Patient Information: Annapolis Neurology Associates

First and Last Name * Date of Birth * Home Address Gender What is your preferred method of contact? * May we leave a detailed message with medical information on your voicemail? If so, which phone number? Email address Home Phone Cell Phone Number Work Phone Number Employer and Occupation Referring Provider Primary Care Provider * Race Ethnicity Primary Language Responsible Party Name of Responsible Party Responsible Party Phone Number Responsible Party Address Responsible Party Date of Birth Relationship to Responsible Party Reason for Visit If motor vehicle accident or workmans compensation Primary Insurance * Secondary Coverage Tertiary Coverage Please print your name as acknowledgment: "I have completed this form entirely and certify that I am the patient or duly authorized agent of the patient to furnish the information requested. I understand that even though I may have insurance coverage, I am ultimately responsible for payment of services rendered *

Reason for visit:

Please give a detailed description of the reason for your visit * Your current Height * Your current Weight * When did the pain or problem start

Medical History:

Diabetes High Blood Pressure Stroke Heart Disease Irregular heart rate Cancer Arthritis Headaches Multiple Sclerosis Seizure/Epilepsy Parkinson's Disease Other Medical Conditions

Prior Hospitalizations and Surgeries:

Hospitalizations Surgeries

Allergies to Medications:

Do you have any allergies to medications? * Please list medications you have allergies to and what the reaction is or state "NKDA": *

Medications:

What pharmacy would you like any prescriptions to be sent to? Please list all medications you take currently, including vitamins, over the counter medications, and supplements or state "None". *

Social History:

Marital Status Caffeinated beverages: Alcohol Use * Number of drinks and frequency (ie. 1 per day or 2 per week) Tobacco Use * If you are a current smoker, how many packs per day? Illicit Drug Use * If you use illicit drugs, what type and frequency?

Family Medical History:

Father's medical condition and if deceased, cause of death and age at death Mother's medical condition and if deceased, cause of death and age at death Sibling 1 medical condition and if deceased, cause of death and age at death Sibling 2 medical condition and if deceased, cause of death and age at death Child 1 medical condition and if deceased, cause of death and age at death Child 2 medical condition and if deceased, cause of death and age at death Child 3 medical condition and if deceased, cause of death and age at death Please print your name to confirm you have completed the Review of Systems to the best of your knowledge. *

Please list the names and complete mailing address of any medical providers that you wish to receive a copy of your office visits and procedures. Please include your primary care provider

Physician Name: Address: Telephone number Fax number Email address Physician name Address Telephone number Fax number Email address

Headache Questionnaire:

Please fill this section out if you are coming in for headaches.

Have you had a Brain MRI or Head CT? If yes, please list the names(s) of the imaging facility How long have you had headaches? How often do they occur? How long do the headaches typically last? Severity of headaches on a scale of 0-10 (if it varies, please give a range) What does the headache feel like? Choose up to 3. Where are the headaches? Do you have any associated symptoms? Do any of the following trigger your headaches? What makes the headache better? Have you taken any of the following medications to reduce the frequency of your headaches (i.e. prevent headaches)? Have you used any of the following treatments/medications to get rid of a headache? Please indicate to the best of your knowledge the reason you stopped any of the above medications. Extra space provided to list any additional information you would like the provider to know about your condition: