Patient Information Appointment Date: Time of Appointment: Marital Status: S M D W Sex: M F

Last Name First Name Middle Name

Birthdate (Mo/Day/Yr)

Race: White American Indian or Alaska Native Black or African American

Asian Native Hawaiian or Other Pacific Islander Prefer not to say/Other

Ethnicity: Hispanic or Latino/a

Not Hispanic or Latino/a

Home Address Street

City, State, Zip Code Email Address

Home Phone ( )

Cell Phone ( )

Business Phone ( )

Employer Name Employer Address

Employer Phone: ( ) With whom is your appointment? Date of Onset of Condition Appointment Reason

**Referring MD Name** **Referring MD Phone Number** ( )

**Primary Care Doctor Name** **Primary Care Doctor Phone Number** ( )

Primary Insurance Company Primary Ins. Phone

( )

Primary Ins. Policy Number Primary Ins. Group Number

Name of Insured Person - Primary Ins. Birthdate of Insured-Primary Relationship to Insured-Primary

Secondary Insurance Company Secondary Ins. Phone

( )

Secondary Ins. Policy

Number

Secondary Ins. Group Number

Name of Insured Person - Secondary Ins. Birthdate of Insured - Secondary Relationship to Insured-Secondary

Nearest Relative to Contact in Case of Emergency Address Phone ( )

** IS THIS AN ACCIDENT/ AUTO ACCIDENT/ LEGAL CASE? YES NO

** IS THIS A WORKERS COMPENSATION CASE? YES NO

** ARE YOU A MEDICARE PATIENT? YES* NO *If yes, please complete the reverse side of this form.

I certify the above information is correct. I understand I am responsible to notify the Neurology Center of Fairfax, LTD if my insurance coverage changes, if benefits change, or if the coverage I have reported is incorrect. I understand and agree that I am ultimately responsible for payment in full for services I receive from the Neurology Center of Fairfax, LTD.

Patient Signature Date

Rev. 07 13 2016

Patient Name: Date of Birth: : MEDICARE PATIENTS ONLY Are you in a rehabilitation facility? YES NO Are you in a skilled nursing facility? YES NO Are you in a nursing center? YES NO Are you in hospice? YES NO

*If yes, please provide the name and address of the facility in the spaces below:

Facility Name:

Facility Address:

Rev. 07 13 2016

New Patient Visit Patient Name: ____________________________ Date of Birth:__________ Date: __________ Family Doctor: _________________ Last Visit: _________

To improve your visit with the doctor:

v Prepare a summary (or chronology) of your illness (one page or less), including when symptoms began. What symptoms did you have at the beginning?

v What brought on the symptoms or made them worse? v What other symptoms have occurred? When did they occur? v What tests have been done? What were the results? v What medications have you taken? What were the results of the treatment? LIST ALL CURRENT MEDICATIONS AND THE DOSE YOU ARE TAKING ON THE SEPARATE MEDICATIONS LIST (OR WE CAN MAKE A COPY OF YOUR LIST). INCLUDE ALL VITAMINS AND OVER-THE-COUNTER MEDICATIONS. Rev. 09 28 2016

Please answer all questions Rev 03.14.2018

NAME: ____________________________________DOB: ________________ PATIENT # __________________

REVIEW OF SYSTEMS

(Symptoms now or in the past 3 months) Systemic Symptoms

Y N Weight Change

Y N Appetite

Y N Chills/fever

Y N Other: _________________

Y N Constitutional symptoms

Head Symptoms

Y N Headache

Y N Facial Pain

Y N Sinus Pain

Y N Other: ________________

Y N Head-related symptoms

Neck Symptoms

Y N Pain in neck

Y N Stiffness

Y N Neck pain radiating down arm

Y N Pain in the arms

Y N Other: __________________

Y N Neck symptoms

Eye Symptoms

Y N Seeing flashing lights

Y N Eye sensitivity to light

Y N Retro-orbital eye pain

Y N Blurry vision

Y N Seeing double (diplopia)

Y N Total loss of vision

Y N Worsening vision

Y N Other: __________________

Y N Eye symptoms

Sleep Symptoms

Y N Snoring

Y N Gasping, choking at night

Y N Insomnia

Y N Daytime sleepiness

Y N Restless/kicking legs

Y N Abnormal body movements while asleep

Y N Other: ________________________

Y N Sleep symptoms

Hematology

Y N Easy bleeding

Y N Anemia

Y N Blood Clots

Y N Other: ______________________

Y N Hematologic symptoms

Otolaryngeal Symptoms (ENT)

Y N Earache

Y N Hearing Loss

Y N Ringing in the ears

Y N Vertigo

Y N Nosebleeds (epistaxis)

Y N Nasal discharge

Y N Sinusitis

Y N Throat Pain

Y N Hoarseness

Y N Disturbed sense of smell

Y N Taste disturbance

Y N Other: ________________

Y N Otolaryngeal symptoms

Cardiovascular Symptoms

Y N Chest pain or discomfort

Y N Heart rate is fast

Y N Palpitations

Y N Heart murmur

Y N Lightheadedness

Y N Heart failure (CHF)

Y N Hypertension

Y N High cholesterol

Y N Other: __________________

Y N Cardiovascular symptoms

Pulmonary Symptoms

Y N Shortness of breath

Y N Cough

Y N Wheezing

Y N Asthma

Y N Chronic obstructive pulmonary disease (COPD)

Y N Other:_________________________

Y N Pulmonary symptoms

Endocrine

Y N Excessive sweating

Y N Excessive thirst

Y N Libido has changed

Y N Diabetes Mellitus

Y N Thyroid disorders

Y N Other: __________________________

Y N Endocrine symptoms

Please answer all questions Rev 03.14.2018

NAME: ___________________________________ DOB: ________________ PATIENT # ___________________

REVIEW OF SYSTEMS (Symptoms now or in the past 3 months)

GI Symptoms

Y N Decrease in appetite

Y N Difficulty swallowing

Y N Heartburn

Y N Nausea/Vomiting

Y N Abdominal pain

Y N Hepatic disorder

Y N Ulcer

Y N Diarrhea

Y N Constipation

Y N Gastrointestinal bleeding

Y N Other:____________________

Y N GI symptoms

Genitourinary Symptoms

Y N Increased urinary frequency

Y N Urinary loss of control

Y N Urinary tract infection

Y N Pain during urination

Y N Kidney stones

Y N Other:______________________

Y N Genitourinary history

Gynecological Symptoms (Women Only)

Y N History of ___ previous pregnancies

Y N Other pregnancy history

Y N Other:______________________

Y N Gynecological history

Musculoskeletal Symptoms

Y N Diffuse joint pains

Y N Limb pain

Y N Pain in the hands and feet

Y N Muscle aches

Y N Muscle twitches (Fasciculations)

Y N Muscle cramps

Y N Other:_______________________

Y N Musculoskeletal symptoms

Back Symptoms

Y N Back pain

Y N Upper back pain (between shoulder blades)

Y N Mid-back pain

Y N Lower back pain

Y N Stiffness of the back

Y N Lower back pain radiating to the legs

Y N Leg pain with exercise (leg claudication)

Y N Muscle cramps in the calf

Y N Other: _____________

Y N Back Symptoms

Skin Symptoms

Y N Itching

Y N Rashes

Y N Easy bruising tendency

Y N Other:____________________

Y N Skin Symptoms __________________

Psychological

Y N Anxiety

Y N Depression

Y N Decreased functioning ability

Y N Unable to control anger

Y N Hallucinations

Y N Interpersonal relationship problems

Y N Other: _______________________

Y N Psychological symptoms

Neurological

Y N Headache

Y N Memory lapses or loss

Y N Confused or disoriented

Y N Total loss of vision

Y N Worsening vision

Y N Seeing double (diplopia)

Y N Loss of hearing

Y N Ringing in the ears (tinnitus)

Y N Dizziness

Y N Vertigo

Y N Difficulties in speech

Y N Difficulty swallowing (dysphagia)

Y N Bowel/bladder changes

Y N Sexual complaints

Y N Localized pain

Y N Generalized pain

Y N Numbness (hypesthesia)

Y N Feeling tired (fatigue)

Y N Muscle weakness

Y N Muscle cramps

Y N Walk is wobbly or unsteady (ataxia)

Y N Poor coordination

Y N Tremor

Y N Convulsions

Y N Fainting (Syncope)

Y N Transient alteration of awareness

Y N Sleep disturbances

Y N Head injury

Y N Spinal cord disease

 

                                                                                                                                                                                                                                                                                                                                                                                                                                                       Rev.  03.29.2017  

Fairfax Office 3020 Hamaker Ct, Suite 400, Fairfax, VA 22031

Reston Office 1830 Town Center Dr, Suite 305, Reston, VA 20190

Office Phone 703.876.0800 | Fax 703.876.0866

After hours emergency 703.755.1450

NAME__________________________________ DOB ________________ PATIENT #________________

Past Medical History

YES YES

Diabetes Mellitus Migraine Headache Type 1(Childhood/Juvenile) Other Headache – type: ____________________ Type 2 (Adult onset) ALS/Lou Gehrig’s Disease Hypertension (High Blood Pressure) Myositis – Muscle Inflammation/Pain Heart Disease – Any Heart Problem Myasthenia Gravis Coronary Disease/Heart Attack/Angina Neuritis – Nerve Pain Atrial Fibrillation or Irregular Heart Beat Nerve Palsy/Paralysis – i.e., Facial Paralysis

Heart failure (CHF) Neuropathy/Numbness High Cholesterol Radiculopathy (Pinched/Trapped Nerve) Joint Problems/Arthritis/Osteoarthritis Cervical Benign Cancer Thoracic Malignant Cancer (including Skin) Lumbar Thyroid Disorders (Hyper- or Hypothyroid) Stroke/TIA /Paralysis GI Disorders Intracranial Hemorrhage Reflux (Gastroesophageal Disease – GERD) Carotid Stenosis/Carotid Surgery Stomach Ulcer/Gastric Irritation Cerebral Aneurysm/Surgery GI Bleed Dementia/Memory Loss Eye Problem/Vision Loss/Double Vision Restless Leg Syndrome Liver Disease Parkinson's Disease History of Infections – incl. Lyme, HIV, Hepatitis Tremor Pulmonary Disease – Any Lung Problem Psychiatric Disorders including AD/HD Pneumonia Depression Asthma Anxiety Chronic Obstructive Pulmonary Disease (COPD) Genetic History (Yours) Kidney Disease – Any Kidney Problem Autoimmune Disease – Lupus, Rheum. Arthritis Hematologic Disorders – Blood Problem Multiple Sclerosis Easy Bleeding Cervical Spine (Neck)Surgery Seizure Disorder/Epilepsy Thoracic Spine Surgery Fainting (Syncope) Lumbar Spine Surgery Sleep Disorders – Trouble Sleeping Surgery – list any other surgeries Sleep Apnea Brain Tumor None/Negative

Additional Information/ Other medical history/tests not listed:

 

                                                                                                                                                                                                                                                                                                                                                                                                                                                       Rev.  03.29.2017  

Fairfax Office 3020 Hamaker Ct, Suite 400, Fairfax, VA 22031

Reston Office 1830 Town Center Dr, Suite 305, Reston, VA 20190

Office Phone 703.876.0800 | Fax 703.876.0866

After hours emergency 703.755.1450

NAME__________________________________ DOB ________________ PATIENT #________________

Family and Social History

Mother Father Sister Brother Mother Father Sister Brother

Diabetes Mellitus Sleep Condition/Insomnia Diabetes Mellitus Type 1 Sleep Apnea Diabetes Mellitus Type 2 Migraine/Other Headache

Hypertension/High Blood Pressure Peripheral Nerve/Muscle Heart Disease – Any heart problem Polyneuropathy - Neuropathy Coronary Disease/Heart Attack/Angina Stroke Syndrome/TIA Atrial Fibrillation – Irregular Heartbeat Intracranial Hemorrhage Heart failure (CHF) Dementia High Cholesterol Restless Leg Syndrome Joint Problems Arthritis Parkinson’s Disease Osteoarthritis Tremor Benign Cancer Psychiatric Disorders Malignant Cancer (including Skin) Depression Thyroid Disorders – Hyper/Hypo Anxiety GI Disorders or Liver Problem Genetic History History of Infections (Hepatitis/HIV) Autoimmune Disease Pulmonary Disease Multiple Sclerosis Pneumonia Other illness not listed Asthma Family history is negative Obstructive Pulmonary Disease (COPD) Family history is unobtainable Kidney Disease – any type Patient adopted Easy Bleeding Patient orphaned Seizure Disorder/Epilepsy Fainting (Syncope) Y Right-handed Y Left-handed

Occupation: Y N Working Full Time Occupation:______________________ Y N Working Part Time Occupation: _____________________ Y N Unemployed Y N Homemaker Y N Retired Y N Currently on disability Y N Student Y N Military service Exercise Habits

Y Good exercise habits (≥ 3 days p/wk) Y Poor exercise habits

Marital History Y N Currently married Y N Domestic Partner Y N Single Y N Separated Y N Divorced Y N Widowed Alcohol Assessment Y N Do you drink alcohol? Y N Social drinker Y N Moderate drinker (2 drinks/day or fewer)

Tobacco Assessment:

Y N Do you use tobacco products?

Smoking Status Y N Current every day smoker Y N Current some day smoker Y N Former smoker Y N Never smoked Y N Smoker, status unknown Y N Unknown if ever smoked Y N Caffeine Use

Continue on reverse side or attach a second sheet, if necessary.

Rev. 07 13 2016

Medication List Mail Order Pharmacy:_________________ Phone:_______________________ Fax: _________________________

Name: _____________________________

DOB: ______________________________ Local Pharmacy:______________________ Phone:__________________________

Cell Phone:_________________________ Fax: ____________________________

Medication/Allergies:______________________________________________________________________________________________________________________________

Medication Dosage Frequency/Time Prescribed By Taken ForPlease include all prescriptions, vitamins, and over-the-counter medications. PLEASE PRINT.

Patient Authorizations

Patient Name: __________________________________________________________________

Date of Birth: ____________________________(Please read carefully. You are authorizing these actions.)

I hereby authorize the Neurology Center of Fairfax, Ltd. (NCF) to apply for benefits on my behalf for covered services rendered by NCF, to myself or to my dependent. Authorization is effective as of today. I request payment from my insurance carrier and/or Medicare Part B to be made directly to NCF.

I certify that the information I have reported with regard to my insurance coverage is correct and further authorize the release of any necessary information, including protected health information (PHI) for this or any other related claim, to my insurance carrier or in the case of Medicare Part B benefits to the Social Security Administration and Centers for Medicare and Medicaid Services (CMS). I permit a copy of this authorization to be used in place of an original. It is possible that services provided to me by NCF may not be covered by Medicare or by my insurance. I agree to assume responsibility for full payment of all services if Medicare or other insurance payment is denied. I further agree to be responsible for the outstanding balance on this account and to pay all reasonable costs of collection including attorney’s fees at 30% of the outstanding balance and monthly interest at 1%, should this account become overdue.

I understand that payment for all services is due and payable in full at the time of service, and that full payment for services may be required at the time of service. This includes, but is not limited to, my co-payment, co-insurance and deductibles. I agree to provide NCF with my current insurance card, government issued identification, and a valid referral (if required) at the time services are rendered. I understand that it is my responsibility to obtain required referrals.

I understand that although my insurance may pay part or all of the charges I incur, I am still ultimately liable and responsible for all charges. I understand that it is my responsibility to know the correct amount of my co-payment and deductible. I understand that my co-payments, co-insurance, and any deductibles are due at the time of service. I understand there is a $10 administrative fee if I do not pay my co-payment, co-insurance, and deductible at the time of service, and a separate $10 administrative fee each time a bill is generated for payment due, but not paid at the time of service. I understand I will be charged a “no-show” fee for any missed appointment or any appointment not cancelled more than 24 hours in advance.

I authorize NCF to release my medical records (protected health information) to my treating physicians and other healthcare providers and to discuss my care with those providers, as my physician deems necessary. I authorize NCF to contact the people whom I list as emergency contacts in the event of an emergency. I authorize NCF to obtain contact information from my other health care providers, my emergency contacts, my employer or my health insurance carrier, if NCF is unable to contact me directly for any reason. I authorize my treating NCF physician to provide information to my caregiver or a family member, if my physician judges this disclosure to be important for my well-being. I authorize NCF to leave messages for me on answering devices attached to my telephones. I authorize NCF to contact me by email to inform me that information is available for me on the NCF secure patient portal. These authorizations may be revoked by me at any time in writing. I agree that a facsimile or a scanned copy of this agreement may be treated as an original for all purposes. I take these actions in Fairfax County, Virginia.

I acknowledge I have received a copy of the Neurology Center of Fairfax, Ltd.’s Notice of Privacy Practices dated July 13,2016. I have read, I understand, and I agree to the terms and conditions specified in this Notice of Privacy Practices

Signature:_____________________________ Date: ________________________****************************************************************************************************************************************************************************

For Patients Who Do Not Have Their Insurance Card, and/or Referral, If Required, (Includes Work Comp)

I acknowledge that I did not bring a referral as required by my insurance company and/or do not have my insurance card. I am electing to be seen today and agree to pay in full today for the services rendered today since I do not have a valid referral and/or insurance card, or worker’s comp authorization.

Signature: ____________________________________________ Date: _____________________________

Rev. 07.13.20162020

**If the patient is under the age of 18, please complete the following:The undersigned is a parent/guardian of the patient and executes this form on behalf of the patient.

Name: _______________________________________________

Signature: ____________________________________________

Relationship: _______________________

Date: _____________________________

Fairfax Office 3020 Hamaker Ct, Suite 400, Fairfax, VA 22031Reston Office 1830 Town Center Dr. Suite 305, Reston, VA 20190Office Phone 703.876.0800 | Fax 703.876.0866After hours emergency 703.755.1450

2020

2020

2020