Name(Required)

First Last

Address

Street Address City State ZIP Code

Mailing Address (If different than physical address)

Street Address City State / Province / Region ZIP / Postal Code

Sex:

Male

Female

Transgender

Marital Status:

D.O.B

Race:

Language:

Employer:

Occupation:

Home Phone:

Preferred Number:

Cell Phone:

Preferred Number:

Work Phone:

May we leave personal/medical information on your voicemail

Yes

Email:(Required)

Last Four of Your SSN:

Self Pay

Yes

INSURANCE COVERAGE:

Primary Insurance: Carrier

ID#:

Group#:

Primary Card Holder:

Self

Spouse/Partner

Other

Name of Insured:

Insured's DOB:

No Secondary Coverage

Secondary Insurance:

ID#:

Group#:

Secondary Card Holder:

Self

Spouse/Partner

Other

Name of Insured:

Insured's DOB:

EMERGENCY CONTACTS

Primary Emergency Contact

I authorize

I do NOT authorize

the disclosure of my protected health information (PHI) to the person listed as my Primary Emergency Contact.

Secondary Emergency Contact

I authorize

I do NOT authorize

the disclosure of my protected health information (PHI) to the person listed as my Primary Emergency Contact.

Name:

Phone Number:

Relationship:

CIRCLE OF CARE

Referring Provider:

Phone Number:

Primary Care Provider:

Phone Number:

Cardiologist:

Phone Number:

Oncologist:

Phone Number:

Pain Management:

Phone Number:

HOW DID YOU HEAR ABOUT US?

PHARMACY

Name:

Phone:

Fax:

Address

Street Address City State / Province / Region ZIP / Postal Code

NO KNOWN DRUG ALLERGIES:

No Known Drug Allergies

MEDICATION ALLERGIES:

Are you allergic to any of the following:

Latex

Adhesives

Contrast

CURRENT MEDICATIONS

Prescriptions

Prescription Name

Dose

Frequency

Reason Prescribed

REVIEW OF SYMPTOMS

Symptoms:

Do you currently have any of the following symptoms?(Within the last 6 months)

NO ISSUES

Anxiety

Back Pain

Burning w/Urination

Chest Pain

Cough

Depression

Diarrhea

Easy bleeding

Easy bruising

Fever

Headaches

Irregular Heartbeat

Joint Pain

Morning Stiffness

Rash

Seizures

Shortness of Breath

Sore Throat

Swelling

Ulcers/Lesions

Wheezing

PERSONAL HISTORY

Please check boxes below if you have been diagnosed with any of the following medical conditions

NO ISSUES

Anemia

Anxiety Disorder(s)

Asthma

Cancer

Coagulation Defects

Colitis

Depression

Diabetes Type I

Diabetes Type II

DVT (Blood Clots)

Epilepsy/Seizures

Heart Disease

Hepatitis

High Blood Pressure

HIV

Kidney Disease

Low Blood Pressure

Lung Disease

Lupus

Osteoarthritis

Rheumatoid

Sleep Apnea

Stomach Ulcers

Stroke

FAMILY HISTORY

Please check boxes if you have been diagnosed with any of the following medical conditions.

NO ISSUES

Anemia

Anxiety Disorder(s)

Asthma

Cancer

Coagulation Defects

Colitis

Depression

Diabetes Type I

Diabetes Type II

DVT (Blood Clots)

Epilepsy/Seizures

Heart Disease

Hepatitis

High Blood Pressure

HIV

Kidney Disease

Low Blood Pressure

Lung Disease

Lupus

Osteoarthritis

Rheumatoid

Sleep Apnea

Stomach Ulcers

Stroke

SOCIAL HISTORY

Height:

Weight:

Right or Left Handed:

Right

Left

Both

Advanced Directive

Do you have a living will?

Yes

Do you have a DNR (Do Not Resuscitate)?

Yes

Blood Products/Transfusions

Do you have any objections to receiving blood or blood products?

Yes

Vaccination Information

Have you had a flu shot?

Yes

If YES, when was your last shot?

MM slash DD slash YYYY

If over 65, have you had a pneumonia vaccine?

Yes

If YES, when was your last shot?

MM slash DD slash YYYY

Do you have a pacemaker?

Yes

If YES, do you take a Beta Blocker?

Yes

Fall: Risk Assessment

If over 65, have you had any falls in the past year?

Yes

If YES, please check one of the following about your fall:

One fall with injury in the past year

Two or more falls with injury in the past year

One fall without injury in the past year

Two or more falls without injury in the past year

Smoking/Tobacco History

Do you currently smoke?

Yes

If YES, how often and how much?

Have you ever smoked?

Yes

If YES, how often and how much?

When did you quit?

MM slash DD slash YYYY

What type of tobacco do you smoke?

Cigarettes

Cigars

Pipe

Snuff

Vape

if you quit smoking, when?

Alcohol Use

Do you currently drink alcohol?

Yes

If YES, what type of alcohol consumed in the past year

Beer

Wine

Liquor

If YES, how often did you have an alcoholic drink in the last year?

Monthly or less

2 to 3 times a week

2 to 4 times a month

4 or more times a week

If YES, how many drinks did you have on a typical day when you drank in the past year?

1 to 2 drinks

3 to 4 drinks

5 to 6 drinks

7 to 9 drinks

10 or more

If YES, how often did you have 6 or more drinks on one occasion in the past year?

Less than a month

Monthly

Weekly

Daily or Almost Daily

Drug Usage

Do you now or have you ever used recreational drugs?

Yes

If yes, please explain:

Prior Surgeries / Please list Month & Year performed

Prior Hospitalizations (Location & Why)

REASON FOR VISIT

New Patient

Second Opinion

Established Patient with New Symptoms

Patient Symptoms:

CONSERVATIVE THERAPY
*Your insurance may require conservative therapy before approving surgery. The following information will help with the approval of any diagnostic test to be ordered or surgery if needed*

Have you had to use a:

Cane

Wheelchair

Walker

Have you tried:

Heat

Ice

Home Exercises

Massage

Diagnostic Imaging: (Within a year from Appointment Date)

No Current Imaging

X-Ray(s)

Cervical

Thoracic

Lumbar

Other

Facility/Location

Cervical

Thoracic

Lumbar

Brain

Other

Facility/Location

MRI(s)

Cervical

Thoracic

Lumbar

Brain

Other

Facility/Location

Medications

Yes

Type:

NSAID(s)

Steroid(s)

Muscle Relaxer(s)

Anti-Inflammatory(s)

Pain Medications

Physical Therapy

Yes

Location:

Chiropractic Care

Yes

Physician Name:

Pain Management

Yes

Physician Name:

Epidural Steroid Injections

Yes

Type:

Cervical

Thoracic

Lumbar

Lumbar Facet Injections:

Yes

Other Procedure(s) or Treatment(s):

Have you missed work for this condition?

Yes

How long have you experienced this pain?

Please indicate your pain level now:

No Pain

PHYSICIAN ONLY SECTION
I have reviewed the listed ROS/PFSH/Screening with the patient and noted the positive/negative findings for the visit.

M.D. Signature:

Date

MM slash DD slash YYYY

TEXAS NEUROSURGERY
ACKNOWLEDGEMENT FORM

Authorize:

TEXAS NEUROSURGERY ACKNOWLEDGEMENT FORM I consent to receive the following documents electronically which are available through our website, unless I request a non-electronic paper copy of the documents disclosed herein.

Texas Neurosurgery’s Notice of HIPAA Privacy Practices

Texas Neurosurgery’s Financial Policy

Texas Neurosurgery’s Medication Policy/Agreement

Texas Neurosurgery’s Physician Assistant Information Guide

Texas Neurosurgery’s Disclosure of Physician Ownership
I authorize: The release of any medical and/or other information necessary to process my claim(s)

Payment of medical benefits to my treating physician or supplier for services rendered by Texas Neurosurgery

Consent for treatment by my treating physician with Texas Neurosurgery

I have read and understand/agree to abide by all the above policies and authorizations of Texas Neurosurgery.

Parent/Guardian Signature

Date

MM slash DD slash YYYY

Comments

This field is for validation purposes and should be left unchanged.

Patient Information Intake Form

Name(Required)

First Last

Address

Street Address City State ZIP Code

Mailing Address (If different than physical address)

Street Address City State / Province / Region ZIP / Postal Code

Sex:

Male

Female

Transgender

Marital Status:

D.O.B

Race:

Language:

Employer:

Occupation:

Home Phone:

Preferred Number:

Cell Phone:

Preferred Number:

Work Phone:

May we leave personal/medical information on your voicemail

Yes

Email:(Required)

Last Four of Your SSN:

Self Pay

Yes

INSURANCE COVERAGE:

Primary Insurance: Carrier

ID#:

Group#:

Primary Card Holder:

Self

Spouse/Partner

Other

Name of Insured:

Insured's DOB:

No Secondary Coverage

Secondary Insurance:

ID#:

Group#:

Secondary Card Holder:

Self

Spouse/Partner

Other

Name of Insured:

Insured's DOB:

EMERGENCY CONTACTS

Primary Emergency Contact

I authorize

I do NOT authorize

the disclosure of my protected health information (PHI) to the person listed as my Primary Emergency Contact.

Secondary Emergency Contact

I authorize

I do NOT authorize

the disclosure of my protected health information (PHI) to the person listed as my Primary Emergency Contact.

Name:

Phone Number:

Relationship:

CIRCLE OF CARE

Referring Provider:

Phone Number:

Primary Care Provider:

Phone Number:

Cardiologist:

Phone Number:

Oncologist:

Phone Number:

Pain Management:

Phone Number:

HOW DID YOU HEAR ABOUT US?

PHARMACY

Name:

Phone:

Fax:

Address

Street Address City State / Province / Region ZIP / Postal Code

NO KNOWN DRUG ALLERGIES:

No Known Drug Allergies

MEDICATION ALLERGIES:

Are you allergic to any of the following:

Latex

Adhesives

Contrast

CURRENT MEDICATIONS

Prescriptions

Prescription Name

Dose

Frequency

Reason Prescribed

REVIEW OF SYMPTOMS

Symptoms:

Do you currently have any of the following symptoms?(Within the last 6 months)

NO ISSUES

Anxiety

Back Pain

Burning w/Urination

Chest Pain

Cough

Depression

Diarrhea

Easy bleeding

Easy bruising

Fever

Headaches

Irregular Heartbeat

Joint Pain

Morning Stiffness

Rash

Seizures

Shortness of Breath

Sore Throat

Swelling

Ulcers/Lesions

Wheezing

PERSONAL HISTORY

Please check boxes below if you have been diagnosed with any of the following medical conditions

NO ISSUES

Anemia

Anxiety Disorder(s)

Asthma

Cancer

Coagulation Defects

Colitis

Depression

Diabetes Type I

Diabetes Type II

DVT (Blood Clots)

Epilepsy/Seizures

Heart Disease

Hepatitis

High Blood Pressure

HIV

Kidney Disease

Low Blood Pressure

Lung Disease

Lupus

Osteoarthritis

Rheumatoid

Sleep Apnea

Stomach Ulcers

Stroke

FAMILY HISTORY

Please check boxes if you have been diagnosed with any of the following medical conditions.

NO ISSUES

Anemia

Anxiety Disorder(s)

Asthma

Cancer

Coagulation Defects

Colitis

Depression

Diabetes Type I

Diabetes Type II

DVT (Blood Clots)

Epilepsy/Seizures

Heart Disease

Hepatitis

High Blood Pressure

HIV

Kidney Disease

Low Blood Pressure

Lung Disease

Lupus

Osteoarthritis

Rheumatoid

Sleep Apnea

Stomach Ulcers

Stroke

SOCIAL HISTORY

Height:

Weight:

Right or Left Handed:

Right

Left

Both

Advanced Directive

Do you have a living will?

Yes

Do you have a DNR (Do Not Resuscitate)?

Yes

Blood Products/Transfusions

Do you have any objections to receiving blood or blood products?

Yes

Vaccination Information

Have you had a flu shot?

Yes

If YES, when was your last shot?

MM slash DD slash YYYY

If over 65, have you had a pneumonia vaccine?

Yes

If YES, when was your last shot?

MM slash DD slash YYYY

Do you have a pacemaker?

Yes

If YES, do you take a Beta Blocker?

Yes

Fall: Risk Assessment

If over 65, have you had any falls in the past year?

Yes

If YES, please check one of the following about your fall:

One fall with injury in the past year

Two or more falls with injury in the past year

One fall without injury in the past year

Two or more falls without injury in the past year

Smoking/Tobacco History

Do you currently smoke?

Yes

If YES, how often and how much?

Have you ever smoked?

Yes

If YES, how often and how much?

When did you quit?

MM slash DD slash YYYY

What type of tobacco do you smoke?

Cigarettes

Cigars

Pipe

Snuff

Vape

if you quit smoking, when?

Alcohol Use

Do you currently drink alcohol?

Yes

If YES, what type of alcohol consumed in the past year

Beer

Wine

Liquor

If YES, how often did you have an alcoholic drink in the last year?

Monthly or less

2 to 3 times a week

2 to 4 times a month

4 or more times a week

If YES, how many drinks did you have on a typical day when you drank in the past year?

1 to 2 drinks

3 to 4 drinks

5 to 6 drinks

7 to 9 drinks

10 or more

If YES, how often did you have 6 or more drinks on one occasion in the past year?

Less than a month

Monthly

Weekly

Daily or Almost Daily

Drug Usage

Do you now or have you ever used recreational drugs?

Yes

If yes, please explain:

Prior Surgeries / Please list Month & Year performed

Prior Hospitalizations (Location & Why)

REASON FOR VISIT

New Patient

Second Opinion

Established Patient with New Symptoms

Patient Symptoms:

Have you had to use a:

Cane

Wheelchair

Walker

Have you tried:

Heat

Ice

Home Exercises

Massage

Diagnostic Imaging: (Within a year from Appointment Date)

No Current Imaging

X-Ray(s)

Cervical

Thoracic

Lumbar

Other

Facility/Location

Cervical

Thoracic

Lumbar

Brain

Other

Facility/Location

MRI(s)

Cervical

Thoracic

Lumbar

Brain

Other

Facility/Location

Medications

Yes

Type:

NSAID(s)

Steroid(s)

Muscle Relaxer(s)

Anti-Inflammatory(s)

Pain Medications

Physical Therapy

Yes

Location:

Chiropractic Care

Yes

Physician Name:

Pain Management

Yes

Physician Name:

Epidural Steroid Injections

Yes

Type:

Cervical

Thoracic

Lumbar

Lumbar Facet Injections:

Yes

Other Procedure(s) or Treatment(s):

Have you missed work for this condition?

Yes

How long have you experienced this pain?

Please indicate your pain level now:

No Pain

PHYSICIAN ONLY SECTION
I have reviewed the listed ROS/PFSH/Screening with the patient and noted the positive/negative findings for the visit.

M.D. Signature:

Date

MM slash DD slash YYYY

TEXAS NEUROSURGERY
ACKNOWLEDGEMENT FORM

Authorize:

Parent/Guardian Signature

Date

MM slash DD slash YYYY

Phone

This field is for validation purposes and should be left unchanged.