2919 W. Swann Ave. Suite 401 Tampa, FL 33609 (813) 872-1548 Fax: (813) 872-7509
New Patient Questionnaire
Name: _________________________ Age: _______ Date of Visit: _____________
Date of Birth: ____________ Referring Physician: ___________________
Primary Care Physician: ____________________
Main Reason for Visit Today: ____________________
Email Address: _______________________________ Phone Number: _________________
Have you been admitted/hospitalized at Tampa General Hospital, Memorial Hospital, or
St. Joseph’s Hospital in the last 3 years? Yes _____ No ______
Do you have history of the following? Current Medications:
Yes
No
Date
Arthritis
Cancer
Cholesterol
problems
Depression
Diabetes
Heart Rhythm
Problem
Heart Attack
High Blood
Pressure
HIV/AIDS
Falls
Multiple
Sclerosis
Memory Loss
Meningitis
Migraine
Headaches
Neuropathy
Seizure
Stroke
Syncope
Other:
Name
Dose
Frequency
Allergies:
_______________________________________
_______________________________________
_______________________________________
Social History:
Martial status: S/M/D/W
Occupation: ___________________________
Children: Yes/No
Tobacco: Yes/No Quit? Yes/No When? ______
Alcohol: Yes/No Frequency? ___________
Drug use? Yes/No
Do you have a living will? Yes/No
Do you have an advanced care plan? Yes/No
Do you have a power of attorney? Yes/No
Name of Surrogate Decision Maker:
_________________ Relationship: ________
2919 W. Swann Ave. Suite 401 Tampa, FL 33609 (813) 872-1548 Fax: (813) 872-7509
Date
Preferred Pharmacy Name:
_______________________________
Address:
_______________________________
Preferred Lab:
LabCorp/Quest/Other: _____________
Did you get the flu shot in 2019 or 2020?
Yes/No
Family Medical History:
Alive/Dead
Cause of
Death/Illnesses
Mother
Father
Sister(s)
Brother(s)
Maternal
Grandmother
Maternal
Grandfather
Paternal
Grandmother
Paternal
Grandfather
Other:
Do you have any of the following conditions?
Yes
No
Yes
No
General
Fatigue
Fever
Weight Loss
Weight gain
Memory Loss
Gastrointestinal
Skin
Rash
Loss of appetite
Skin Cancer
Nausea
Head/Neck
Headaches
Vomiting
Head injury
Blood in stool
Neck pain
Changes in bowel habits
Blurred vision
Ulcers
Double vision
Gynecological
Hearing loss
Irregular menses
Ears ringing
Abnormal vaginal
bleeding
Vertigo or
dizziness
Pregnancy
Hoarseness
Contraceptive use
2919 W. Swann Ave. Suite 401 Tampa, FL 33609 (813) 872-1548 Fax: (813) 872-7509
Difficulty
swallowing
Post-menopausal
Respiratory
Cough
Behavioral
Asthma
Drug abuse
Shortness of
breath
STD
Pneumonia
Insomnia
Tuberculosis
Hematological
Cardiac
Angina/chest
pain
Transfusions
Irregular heart
beat
Anemia
Heart failure
Cancer/malignancy
Rheumatic
fever
Clotting disorder
Renal/Urinary
Kidney devices
Endocrine/Metabolic
Change in
bladder
function
Diabetes
Blood in urine
Thyroid problems
Kidney stones
Bone/Joints
Emotional/
Psychiatric
Depression
Pain
Anxiety
Swelling
Suicidal
thoughts
Injury
Previous
psychological
counseling
What is your primary concern to discuss with your neurologist at your appointment?
__________________________________
2919 W. Swann Ave. Suite 401 Tampa, FL 33609 (813) 872-1548 Fax: (813) 872-7509
Name: ___________________________ Date of Birth: ________________ Gender: _______
Home Address: ____________________________ City: ________________ State: ________
Zip Code: ____________ Phone Number: ___________________ Email: ________________
Employer: _____________________ Address: ______________________________________
Business Phone: ________________
Emergency Contact Name: _________________ Relationship: ________________________
Phone Number: __________________
Primary Insurance:
Insurance Company: ________________
Address: ___________________________
City: _________ State: _____
Zip Code: _________
Policy Holder Name: _________________
Subscriber Name: ______________
Group Number: _______________
Supplemental Insurance:
Insurance Company: ________________
Address: ___________________________
City: _________ State: _____
Zip Code: _________
Policy Holder Name: _________________
Subscriber Name: ______________
Group Number: _______________
Workmen’s Compensation: Were you injured on the job? Yes ____ No ____ Date:__________
Employer: ___________________ Insurance Company Responsible for Claim: __________
Adjustor’s Name: _____________________ Address: ________________________________
City: _____________ State: _______ Zip Code: _________
Public Liability: Is this the result of an accident? Yes ____ No ____ Date:__________
Attorney’s Name: _____________________ Phone Number: ____________________
Insurance Company Responsible for Claim: _________________
Name of Insured: ___________________ Address of Insurance Company: ______________
2919 W. Swann Ave. Suite 401 Tampa, FL 33609 (813) 872-1548 Fax: (813) 872-7509
Patient Consent and Authorization Form
I understand that I have certain rights to privacy regarding my protected health information. These rights
are given to me under the Health Insurance and Accountability Act of 1996 (HIPAA). I understand that
by signing this consent, I acknowledge receipt of notice of privacy and authorize you to use and disclose
my protected health information to, and inclusive of:
Disclose the patient’s personal health information, treatment, billing, and payment. Disclose the patient’s
diagnosis for related lab and diagnostic centers where treatment is rendered as requested by Tampa
Neurology Associates, LLC/Neuroscience Consultants, LLP.
I understand that I have the right to request restrictions on how my protected health information is used
and disclosed to carry out treatment and health operations, but that Tampa Neurology Associates, LLC is
not required to agree to the restrictions. However, if Tampa Neurology Associates, LLC/Neuroscience
Consultants, LLP agree, you are then bound to comply with this restriction.
If I revoke this consent, Tampa Neurology Associates, LLC/Neuroscience Consultants, LLP does not
have to provide any further healthcare services to the patient.
My signature below indicates that I have been given the chance to review a current copy of the Tampa
Neurology Associates, LLC/Neuroscience Consultants, LLP Notice of Privacy Practices. This can be
found at www.fcneurology.net or can be provided upon request. My signature indicates that I agree to
follow Tampa Neurology Associates, LLC/Neuroscience Consultants, LLP to use and disclose my
personal health information to carry out treatment, payment and healthcare operations.
Print Patient Name: ________________________ Relationship to Patient: _______________
Signature: ___________________________ Date: ________________
Financial Agreement/Assignment of Benefits:
I hereby authorize payment to be made directly to Tampa Neurology Associates, LLC/Neuroscience
Consultants, LLP of benefits due to me from my insurance company. The responsible parties agree to pay
for all fees, services and treatment incurred by the patient. If there is a fee that is not covered by
insurance, this is payable by the patient. The patient also agrees to pay for all deductibles, co-payments
and non-covered services. After receipt of a statement, if payment is not received by the next billing
cycle, it is subject to a monthly finance charge. If an account is referred to an outside agency for
collection, the patient agrees to pay for all such action. An account will be referred to a collection service
if no payment has been received within 90 days of service.
Signature: ___________________________ Date: ________________
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2919 W. Swann Ave. Suite 401 Tampa, FL 33609 (813) 872-1548 Fax: (813) 872-7509
Patient Health Questionnaire (PHQ-9)
Name: ______________________ Date: ______________
Over the last two weeks, how often have you been bothered by any of the following
problems? Use an “X” to indicate your answers.
Not at
All
(0)
Several
Days (1)
More than Half
the Days (2)
Nearly Every
Day (3)
1. Little interest or pleasure in
doing things
2. Feeling down, depressed, or
hopeless
3. Trouble falling or staying
asleep, or sleeping too much
4. Feeling tired or having little
energy
5. Poor appetite or overeating
6. Feeling bad about yourself or
that you are a failure, or have let
yourself or your family down
7. Trouble concentrating on
things, such as reading the
newspaper or watching
television
8. Moving or speaking so slowly
that other people have noticed;
or the opposite, being so fidgety
or restless that you have been
moving around a lot more than
usual
9. Thoughts that you would be
better off dead or hurting
yourself in some way
Total Score:
Interpretation of Total Score for Depression Severity:
1-4: Minimal depression
5-9: Mild depression
10-14: Moderate depression
15-19: Moderately severe depression
20-27: Severe depression