Narendra Kansal, MD - Publicforms

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APPOINTMENT REQUEST BACK OR LEG DISABILITY FORM HIPPA NOTICE/ CONSENT FORM MEDICATION REFILL REQUEST NECK DISABILITY FORM NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW ASSIGNMENT OF BENEFITS FORM NO FAULT CLAIMANT HISTORY FORM NO FAULT INFORMATION SHEET PATIENT INFORMATION PART 2 PATIENT INFORMATION SHEET 1 RECORDS RELEASE FORM REVIEW OF SYSTEMS Welcome to our Neurosurgery practice. WORKERS COMPENSATION INFORMATION SHEET

REVIEW OF SYSTEMS

Please check box the symptoms you have been experiencing recently. you MUST select at least one in each category, if none select NONE.

Name *

Date *

GENERAL:

Select all that apply: *

WEIGHT LOSS

FATIGUE

WEAKNESS

FEVER

CHILLS

NIGHT SWEATS

NONE

HEENT: (head, eyes, ears, nose, throat)

Select all that apply: *

VISION CHANGES

HEARING LOSS

RINGING IN THE EARS

NOSE BLEEDS

NONE

NECK:

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PAIN

DIFFICULTY SWALLOWING

SORE THROAT

LUMPS/MASSES IN NECK

HOARSENESS

NONE

RESPIRATORY

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SHORTNESS OF BREATH

WHEEZING

DRY COUGH

PRODUCTIVE COUGH

NONE

CARDIAC

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PALPITATIONS

CHEST PAIN

SHORTNESS OF BREATH WHEN LAYING DOWN

SWELLING IN LEGS

SHORTNESS OF BREATH WHEN EXERCISING

NONE

GI:

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NAUSEA/VOMITING

DIFFICULT SWALLOWING

INDIGESTION

CHANGE IN BOWEL HABITS

BLOOD IN STOOL

WEIGHT LOSS

NONE

GU:

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DIFFICULTY URINATING

PAIN IN URINATING

PROSTATE PROBLEMS

URINATING MULTIPLE TIMES AT NIGHT

BLOOD IN URINE

NONE

VASCULAR

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PAIN IN CALVES WHEN WALKING

CLOTS IN LEGS

NONE

MUSCULOSKELETAL:

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PAIN/STIFFNESS IN BONES OR JOINTS

ARTHRITIS

GOUT

MUSCLE WEAKNESS

NONE

NEUROLOGIC

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NUMBNESS/WEAKNESS

TINGLING

TREMORS

SEIZURES

BLACKOUTS

HEADACHES

NONE

HEMATOLOGIC:

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EASY BRUISING

EASY BLEEDING

NONE

ENDOCRINE

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HEAT INTOLERANCE

COLD INTOLERANCE

EXCESSIVE THIRST

NONE

SKIN

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SKIN CHANGES

NAIL CHANGES

HAIR CHANGES

RASHES

SORES

NONE

PSYCHIATRIC:

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DEPRESSION

ANXIETY

THOUGHTS OF SUICIDE

NONE

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