Fill - Free fillable New Patient Questionnaire PDF form

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

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

Past Surgeries

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

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

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

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