ࡱ> c bjbj ^\^\D G\ hhh4hLP~$#######$v%,(`#$h0#$8$###h#####(@# Gf##N$0~$#( ((#(h#D##$#$G#^~$(> N:  Welcome to the BWH Department of Neurology Who referred you to us? (List the Physicians name/address/phone): _____________________________________________________________________________________ ______________________________________________________________________________________ Other physicians, including your neurologist, who should receive correspondence regarding your care: [ 1 ] Name: _____________________________ Address: _______________________________ _______________________________________ Phone: _________________________________ [ 2 ] Name: _____________________________ Address : _______________________________ _______________________________________ Phone: _________________________________  For what problem were you referred today?___________________________________________________ Describe your symptoms: _________________________________________________________________ ______________________________________________________________________________________ Describe your medical history; please list all medical conditions and hospitalizations you have ever had (include dates):________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________Describe your surgical history; please list all major surgeries and procedure you have ever had (include dates): ________________________________________________________________________________ ______________________________________________________________________________________ Describe any known allergies:______________________________________________________________ Has anyone in your family ever had a brain tumor, seizures or epilepsy, dementia, Parkinsons, multiple sclerosis, muscle disease, neuropathy, other neurological disorder? If yes, please describe and give relationship of family member:_____________________________________________________________ Any other medical problems run in your family?_______________________________________________ Do you use tobacco products? If yes, describe_________________________________________________ Do you consume alcohol? If yes, what/how much per week:______________________________________ Do you have children? ______________________ Marital Status?_________________________________ Whom do you live with?__________________________________________________________________ Do you have a job? YES / NO If yes, please describe________________________________ __________ Are you receiving disability? YES / NO If yes, are you on permanent or temporary disability? Are you experiencing any sexual dysfunction?:________________________________________________ Are you trying for a pregnancy?:____________________________________________________________ Do you have a healthcare proxy? If yes, who is it?_________________________If no, and want more information, please ask the receptionist. LIST CURRENT MEDICATIONS: Drug NameDoseFrequencyRefills Needed?  Date:___________Time:________Patient Signature:___________________________________ Date:___________Time:________Physician Signature:____________________________Clinical ID#_________     TURN OVER FOR OTHER SIDE NEW PATIENT VISIT FORM (10/08) YES NO                                         Cardiac System Do you have chest pains? Do you have palpitations? Gastrointestinal System Have you lost your appetite? Have you lost weight unexpectedly? Do you have indigestion or heartburn? Do you have stomach pains? Do you have constipation or diarrhea? Do you have nausea or vomiting? Urinary System Do you have burning while urinating? Do you have blood in your urine? Do you wake up at night to urinate? Do you have to rush to urinate? Do you lose control over urinating or stool? Musculoskeletal System Do you have neck pain? Do you have back pain? Do you have joint pains? Where? _____________ Are you being physically abused by anyone? General Do you have fevers? Do you have night sweats? Do you have fatigue? YES NO                                                 REVIEW OF SYSTEMS: Neurological System Do you have a headache? Do your headaches wake you up at night Do you have seizures? Have you ever lost consciousness for other reasons? Do you have weakness? Do you have numbness? Do you have dizziness? Do you have double vision? Do you have blurred vision? Do you have confusion? Do you have memory loss? Do you have trouble walking? Can you take care of yourself? Do you fall? Mental Health Do you feel depressed? Do you have sleeping problems? Do you feel anxious? Do you feel threatened by anyone? Are you being mentally abused by anyone? Respiratory System Do you have a cough? Do you cough up thick mucus? Have you coughed up blood? Do you have shortness of breath? 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A"@@2I1R%䲇:]$%Xu$]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd 0  # A2I1R%䲇:]$%XP&]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd >  # A"@@2I1R%䲇:]$%X(]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd 0  # A2I1R%䲇:]$%X)]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd >  # A"@@2I1R%䲇:]$%X+]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd 0  # A2I1R%䲇:]$%X-]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd >  # A"@@2I1R%䲇:]$%Xm/]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd 0  # A2I1R%䲇:]$%XH1]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd >  # A"@@2I1R%䲇:]$%X3]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd 0  # A2I1R%䲇:]$%X4]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd >  # A"@@2I1R%䲇:]$%X6]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd 0  # A2I1R%䲇:]$%X8]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd >  # A"@@2I1R%䲇:]$%Xe:]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd 0  # A2I1R%䲇:]$%X@<]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd >  # A"@@2I1R%䲇:]$%X >]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd 0   # A2I1R%䲇:]$%X?]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd > ! # A"@@ 2I1R%䲇:]$%XA]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd > " # A"@@!2I1R%䲇:]$%XC]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd > # # A"@@"2I1R%䲇:]$%XkE]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd 0 $ # A#2I1R%䲇:]$%XFG]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd > % # A"@@$2I1R%䲇:]$%XI]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd 0 & # A%2I1R%䲇:]$%XJ]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd > ' # A"@@&2I1R%䲇:]$%XL]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd 0 ( # A'2I1R%䲇:]$%XN]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd > ) # A"@@(2I1R%䲇:]$%XcP]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd 0 * # A)2I1R%䲇:]$%X>R]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd > + # A"@@*2I1R%䲇:]$%X T]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd 0 , # A+2I1R%䲇:]$%XU]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd > - # A"@@,2I1R%䲇:]$%XW]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd 0 . # A-2I1R%䲇:]$%XY]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd > / # A"@@.2I1R%䲇:]$%X[[]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd 0 0 # A/2I1R%䲇:]$%X6]]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd > 1 # A"@@02I1R%䲇:]$%X_]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd 0 2 # A12I1R%䲇:]$%X`]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd > 3 # A"@@22I1R%䲇:]$%Xb]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd 0 4 # A32I1R%䲇:]$%Xd]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd > 5 # A"@@42I1R%䲇:]$%XSf]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd 0 6 # A52I1R%䲇:]$%X.h]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd > 7 # A"@@62I1R%䲇:]$%Xi]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd 0 8 # A72I1R%䲇:]$%Xk]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd > 9 # A"@@82I1R%䲇:]$%Xm]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd 0 : # A92I1R%䲇:]$%X~o]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd > ; # A"@@:2I1R%䲇:]$%XKq]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd 0 < # A;2I1R%䲇:]$%X&s]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd > = # A"@@<2I1R%䲇:]$%Xt]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd 0 > # A=2I1R%䲇:]$%Xv]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd > ? # A"@@>2I1R%䲇:]$%Xx]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd 0 @ # A?2I1R%䲇:]$%Xvz]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd > A # A"@@@2I1R%䲇:]$%XC|]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd 0 B # AA2I1R%䲇:]$%X~]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd > C # A"@@B2I1R%䲇:]$%X]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd 0 D # AC2I1R%䲇:]$%XƁ]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd > E # A"@@D2I1R%䲇:]$%X]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd 0 F # AE2I1R%䲇:]$%Xn]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd > G # A"@@F2I1R%䲇:]$%X;]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd 0 H # AG2I1R%䲇:]$%X]`!1R%䲇:]$NNXXxcdd``> "@ X>( S C ؄L `0HF&&\ Y ,.# L QIs0L+dq` M-VK-WMcػK1 F5l'~&^ av fKtv UL @P b5DZŇ,M/ d ̆3 >8Dd > I # 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