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1400 Sourn Onraxoo Avnuur, Surrs 301Wnrrn Pnnx, Flontol 32789-5553

TnrPnoNr (407') 645-3151

Fax (407) 645-2\79

Appt Date: APPI Time:

Dear:

You have been referred to Dr' for neurology consultation by your

personal physician. This evaluation will consist of a careful history of your problem followed by a

neurologic examination, a discussion of the findings with the doctor, and recommendations for further

testing or treatment as indicated. This initial evaluation generally lasts for 45 minutes to one hour.

We are Medicare Participating Providers and participate in a number of HMO and PPO plans. You

should confirm our participation directly with your insurance provider and be sure to bring any required

referral forms to your appointment.

We attempt to confirm appointments by telephone. Please notify us if your home, work, or mobile

number changes. Your appointment will be canceled if we cannot reach you due to a disconnected

telephone number. Patients under the age of 18 must be accompanied by a parent or guardian. So that

your appointment will be as productive as possible, we ask that prior arrangements be made forchildren and/or siblings of the patient whenever possible. As a courtesy to the doctor and other

patients, we request that you notify the office in advance if you will be unable to keep your

appointment.

Please complete the enclosed forms and bring them with you to your appointment. Please also bring

any pertinent imaging films/CDs to your appointment'

I'**PLEASE NOTE THAT WE ARE LOCATED ON SOUTH ORTANDO AVENUE (HWY 17.92} IN WINTER PARK. PTEASE

MAKE SURE THAT YOUR GPS DOESN'T DEFAUTT TO ORANGE AVENUE IN ORLANDO.

TO DAYTONA TO t,IAITLAI{D

1400 s oRLAllDO

(Three StorY Building)

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N.&UROL O G Y and E t EC TR O{VIVO'G,R'{F H Y C ON,SIULTANT S, P. A.1400 souTII ORLANDO AVEI\U[, SUITE 301 . WINTER PARK, FL 32789

PHONE (407) 64s-3151 . FAX (407) 64s-2179

COPAY: $

PATIENTNAME: DATE OF BIRTH: AGE:

ADDRESS: PATIENT'S SS#:

CITY/STATEI ZIP: PARENT''S SS# (if minor child):

HOME PHONE: WORK PHONE: CELL PHONE:

PATIENT/PARENT EMPLOYER: NAME OF SPOUSE/PARENT:

RELATIVE/CONTACT (not at same address): TELEPHONE:

ADDRESS: CltvlstarB; I zrPtI

REASON FORCONSULTATION (check one):

ILLNESS: AUTO: WORK COMP: DATE OF INJURY:

PRIMARY INSURANCE CARRIER SECONDARY INSURANCE CARRIER

CARRIER: CARRIER:

ADDRESS: ADDRESS:

CITY/STATE: CITY/STATE:

TD#: ID#:

GROUP#: GROUP#:

INSURED: INSURED:

CLAIM#: CLAIM#:

****IF MEDICARE, DO YOU HAVE PART D? n vrs !NoTELEPHONE:FAMILY DOCTOR:

*****I.FOR OFFICE USE ONLY*****'b

DATE OF REFERRAL; DATE OF CONSULTATION:

OFFICE: EMG: IIOSP F/U: IME: EVAL/TX: I EVAL ONLY:

REFERRING PITYSICIAN: TELEPHONE:

ADDRESS: FAX:

UPIN:

iREASON FORREFERRAL:

PATIENT ID#: DOCTOR: STAFF INITIAL: I UPDA'I'ED:

PLEASE FILL OUT THIS FORM COMPLETELY AND BRING IT WITH YOU TO OUR OFFICE FOR YOUR APPOINTMENT.

ALL INFORMATION IS STRICTLY CONFIDENTIAL AND WILL NOT BE RELEASED EXCEPT UPON YOUR REQUEST OR BY

SUBPOENA.

PATIENT NAME: DATE OF BIRTH:

please describe the problem for which you were referred to a neurologist for evaluation:

lf you are beingtreated by any physician(s) otherthan the referring physician, please list them and the problem

they are treating:

please list ALL mediations that you are now taking, including hormones and any non-prescription medicines.

lndicate strensth and how often taken:

ALLERGIC TO: EFFECT:

Do you smoke?

-now -in

past only-never

FAMILY HISTORY:

Relation Aee if Living Age at Death Current State of Health or Cause of Death

Father

Mother

sisters

Or

Brothers

Children

Does anyone is your family have (make an X if yes):

( ) Diabetes

( ) Cancer

( ) High Blood Pressure

O Epilepsy

( ) Headache

( ) Stroke

() Heart Disease

( ) Tuberculosis

( ) Disease ofthe Nervous SYstem

t ) Any lnherited Disease

Are you

-left

handed

-right

handed?

Relationship

.'\

(OVER PLEASE)

Do you have or have you had (make an X if yes):

Year

( ) Asthma

( ) Recurrent Bronchitis

( ) Cancer

( ) Chest Pain

( )Hieh Blood Pressure

( ) Heart Attack

( ) lrregular Heart Rhythm

( ) Palpitations

( ) Heart Murmur

( ) Heart Failure

( ) Shortness of Breath w/Exertion

( ) Shortness of breath at rest

( ) Coughed Up Blood

( ) Sinus Trouble

( ) Dizzy Spells

( ) Hearing Loss

( ) Ringing of Ears

( ) Head lnjury

( ) Severe Headache

( ) Convulsions

( ) Difficulty with Memory

( ) Diverticulitis

( )Abnormal Bleeding

( ) lndigestion

( ) Stomach Pain

( ) Tarry Stools

( ) Recurrent Diarrhea

( ) Gallbladder Attacks

( ) Recurrent Constipation

( )Arthritis

Year

What Kind?

List any diagnostic tests, scans or x-rays you have had in connection with the problem for which you are being

seen. lnclude type of test, date, where done, and results. lF APPOINTMENT lS DUE TO AN ABNORMAL X-RAY OR

SCAN, PLEASE BRING THE CD TO YOUR APPOINTMENT.

please list hospitalizations or operations you have had in the last 10 years, plus any operations prior to that time.

Please give name and city of the hospital and the reason for the admission'

Do you presently drive a car or other vehicle? YES

-

NO

Please feel free to discuss any other relevant information'

Signature Date

PLEASE REMEMBER TO BRING THIS FORM TO YOUR APPOINTMENT AND PRESENT IT TO THE RECEPTIONIST WHEN

YOU CHECK IN, THANK YOU,

Neurology & EMG Consultants

1400 S. Orlando Avenue, #301

Winter Park, FL 32789

(407) 64s-31s1

FAMILY€ONSENT T'ORM

Please list below any family mernbers or close friends with whom we may discuss yorumedical condition.

Name Rgblionship phone Number

Please list below any contact persons with whom we may leave messages.

Name Relationship phone Number

we may leave messages about appointnents on yourhome answering machine.

we may leave messages about appointnents on voice mail at your job.Initials

Signature of Patient Date