Patient intake – pg 1

University Neurosurgery LSU Health Sciences Center- Shreveport

Patient Intake Form

Name:______________________________________________________________ DOB:___________________

Age:______________ Primary Care Physician:_____________________________________________________

Medication Name: Dosage: How Taken? How Often? Last Taken?

SOCIAL HISTORY:

Marital Status (circle): Single Married Divorced Widowed

Smoke: YES NO Packs per day __________ Alcohol: YES NO Drinks per day__________ Illicit Drugs: YES NO How often?____________

Height: ________ft________inches Weight: ________ lbs

Allergic to: Reaction:

Patient intake – pg 2

MEDICAL HISTORY: Please mark (yes/no) for pertinent past medical history. If you do not see a specific medical problem, please list below.

Allergies YES NO Depression YES NO Nerve/muscle disease YES NO Anemia YES NO Diabetes mellitus YES NO Osteoporosis YES NO Anxiety YES NO Emphysema YES NO Seizures YES NO Arthritis YES NO GERD YES NO Sickle cell anemia YES NO Asthma YES NO Glaucoma YES NO Stroke YES NO Blood transfusion YES NO Heart murmur YES NO Substance abuse YES NO Cancer YES NO HIV/Aids YES NO Thyroid disease YES NO Cataracts YES NO Hypertension YES NO Tuberculosis YES NO CHF YES NO Kidney disease YES NO Ulcers YES NO Clotting disorder YES NO Kidney disease YES NO Ulcers YES NO COPD YES NO Myocardial infarction YES NO

SURGERIES: Please mark (yes/no) for all surgeries in which you have undergone. If you do not see a surgery you have had, please list below.

Appendectomy YES NO C-Section YES NO Prostate surgery YES NO Brain surgery YES NO Eye surgery YES NO Small intestine surgery YES NO Breast surgery YES NO Fracture surgery YES NO Spine surgery YES NO CABG YES NO Hernia repair YES NO Tubal ligation YES NO Cholecystectomy YES NO Hysterectomy YES NO Valve replacement YES NO Colon surgery YES NO Joint replacement YES NO Vasectomy YES NO Cosmetic surgery YES NO YES NO YES NO

Patient intake – pg 3

MEDICAL SYMPTOMS/COMPLAINTS: Please check each current symptom and/or complaint for which you are having. Constitution: Eyes GU Neurological Activity change Eye discharge Difficulty urinating Dizziness Appetite change Eye itching Dyspareunia Facial asymmetry Chills Eye pain Dysuria Headaches Diaphoresis Eye redness Enuresis Light-headedness Fatigue Photophobia Flank pain Numbness Fever Visual disturbance Frequency Seizures Unexpected weight

change Genital sore Speech difficulty

Respiratory Hematuria Syncope

Apnea Menstrual problem Tremors

HENT Chest tightness Pelvic pain Weakness Facial swelling Choking Urgency Hematologic Neck pain Cough Urine decreased Adenopathy Neck stiffness Shortness of breath Vaginal bleeding Bruises/bleeds easily Ear discharge Stridor Vaginal discharge Hearing loss Wheezing Vaginal pain Psychiatric Ear pain MS Agitation Tinnitus Cardiovascular Arthralgias Behavior problem Nosebleeds Chest pain Back pain Confusion Congestion Leg swelling Gait problem Decreased concentration Rhinorrhea Palpitations Joint swelling Dysphoric mood Postnasal drip Myalgias Hallucinations Sneezing GI Skin Hyperactive Sinus pressure Abdominal distention Color change Nervous/anxious Dental problems Abdominal pain Pallor Self-injury Drooling Anal bleeding Rash Sleep disturbance Mouth sores Blood in stool Wound Suicidal ideas Sore throat Constipation Trouble swallowing Diarrhea Voice change Nausea Rectal pain FAMILY HISTORY: Please mark accordingly.

Relationship Alcohol a

buse

Arthrit

is

Asthma

Birth d

efects

Cancer

COPDDepre

ssion

Diabetes

Drug abuse

Early

death

Hearing lo

ss

Heart dise

ase

Hyperte

nsion

Kidney di

sease

Learning disa

bilities

Mental illness

Mental retar

dation

Miscarri

ages

Stroke

Vision Lo

ss

Mother

Father

Sister

Brother

Daughter

Son

Last First Middle

Name:

Date of Birth: / SSN: Male Female

Address: City State Zipcode

Home Phone: Work Phone: Cell:

Last First Middle

Name:

Phone: Relationship:

In order to ensure that treating physician(s) receive a copy of the dictation from your visit with University Neurosurgery, we need

for you to provide the names (first and last names), addresses, and phone numbers of all doctors that you are currently under the care of. Please

indicate which is referring and which is your primary care physician (PCP). If you have additional doctors, you may write their information

on the back of this sheet, Thank you for your time.

Responsible Party:

Insurance Coverage:

My illness is due to (please circle one): Accident Work Injury Other Date of Injury: / /

Insurance #1

Name of Insurance Company:

Group #:

Policy #:

Policy Holder: DOB / /

Insurance #2

Name of Insurance Company:

Group #:

Policy #:

Policy Holder: DOB / /

Referring Physician

Doctors Name:

Address:

City/State:

Primary Care Physician

Doctors Name:

Address:

City/State:

I give my consent to communicate with the following physicians regarding my care:

/

Street

Cardiologist

Doctors Name:

Address:

City/State:

Hematology/Oncologist

Doctors Name:

Address:

City/State:

Radiation/Oncologist

Doctors Name:

Address:

City/State:

Nephrologist/Pulmonologist

Doctors Name:

Address:

City/State:

Patient Signature: Date: / /

Patient Information

Louisiana State UniversityHealth Sciences Center - ShreveportFaculty Group Practice Neurosurgery Clinic

Alternative Contacts and Treatment We take your medical confidentiality very seriously. We will not and cannot release information without your written authorization.

This authorization allows our staff members to speak only with an individual(s) you designate in the event you are not available to receive phone calls or you have an adult member that helps coordinate your medical care. You should not designate your doctor.

We will not leave any health information with any other person unless you specifically authorize below: I do not authorize anyone to receive information regarding my medical care. I authorize my physician and the employees of this clinic to speak with:

1. Person: ______________________________________ Relationship: ______________________Phone number(s): _____________________________________________________________ Appointments Account/Bill Lab Results Test Results Medical Care Treatment

2. Person: ______________________________________ Relationship: ______________________Phone number(s): _____________________________________________________________ Appointments Account/Bill Lab Results Test Results Medical Care Treatment

3. Person: ______________________________________ Relationship: ______________________Phone number(s): _____________________________________________________________ Appointments Account/Bill Lab Results Test Results Medical Care Treatment

Alternate means of contacting me are:My answering machine / voice mail / pager: ___________________________________________________Cell Phone: ____________________________________________________________________________My Email: ______________________________________________________________________________My fax number: _________________________________________________________________________Other: _________________________________________________________________________________

This authorization will remain in effect unless changed by me while I am a patient at this office.It is my responsibility to notify this office of changes and to complete a new form.

I agree that should I desire to revoke this authorization, I will give written notice.

PATIEnT SIgnATuRE: _____________________________________________PATIENT DOB:______/______/________

PATIENT PRINTED NAME:____________________________________________________________________________

PAREnT/guARdIAn SIgnATuRE:_____________________________________________________________________

WITnESS SIgnATuRE: ______________________________________________________________________________

dATE: ___________________________________ TIME: _________________________________

LSUHSC-S 7989 Rev. 9/2017