Patient Intake Form

Georgetown University Hospital Neurosurgery Patient Forms

Page 1 of 3 - Patient History Intake Form

Georgetown University Hospital Date:

Department of Neurosurgery

Patient History Intake Form

Name: DOB: Age: Sex: M F

Height: Weight: Working? Yes No Occupation:

Your primary family physician name, address, phone number:

Were you referred by a physician? Yes No

If yes, referring physician's name, address, and specialty:

Phone #

If no, who referred you?

Is GUH permitted to send medical records to referring physician/clinic? Yes No

What problem(s) are you seeking treatment for today?

Was this problem the result of an accident or injury? Yes No

Is this condition a result of a Worker's Compensation injury? Yes No

If yes, name of Worker's Compensation Carrier:

Have you had back problems in the past? Yes No

If yes, type and number of years:

What kind of evaluations have you had for this pain? (Please check all that apply)

MRI CT scan X-rays EMG Myelogram Other:

Results as you understand them:

Current Symptoms

How long has your current problem been present? Other:

How did the pain start? Suddenly Gradually After Injury

How often do you have the pain? Daily Intermittent Infrequent

Is your pain: Variable Constant

How would you describe your pain? (Please check all that apply)

Other: Aching Burning Stinging Pressure Tingling Stabbing

What makes your pain worse? (Please check all that apply)

Other: Lifting Bending Twisting Coughing Straining Sitting Standing Walking Sneezing Running Lying Down Changing Position

What makes your pain better? (Please check all that apply)

Other: Ice Sitting Lying down Resting Heat Standing Medications

Do you have any of the following? (Please check all that apply)

Fevers Chills Numbness Tingling Weakness in arm or leg Unexplained weight loss Night Sweats Smoking History Radiation of pain into arm or leg Bowel or bladder problems Sexual Dysfunction

What treatments have you had for this current pain? (Please check all that apply)

Physical Therapy Surgeries TENS unit Injections Acupuncture Chiropractic Massage Explain Treatments:

Prior Hospitalization? Yes No

1.) Date: Reason:

2.) Date: Reason:

3.) Date: Reason:

4.) Date: Reason:

Page 2 - Pain Regions / Pain Rating Face Scale

The pain regions diagram on page 2 is an informational body map. Please indicate pain locations in the space below:

Pain rating face scale: Please circle above rating pain level (0 to 10).

Pain level:

Page 3 of 3 - Review of Systems / Medical History / Social History

Name: Date:

Review of Systems: Do you have any problems with the following? (Please check all that apply)

Tuberculosis Exposure Calf Pain Irregular Heart Rate Excessive Stress Hearing Loss Fever Difficulty Emptying Bowel / Bladder Chest Pain Seizures Coughing Dental Problems Shortness of Breath Excessive Bruising Stomach Trouble / Ulcers Coughing Up Blood Excessive Thirst Enlarged Glands Headaches Double Vision Joint Pain or Swelling Black-Outs Weight Gain or Loss Greater Than 10 lbs.

Abnormal swelling? Where? Explain:

Other:

Past Medical History: (Please check all the items that have been issues for you)

Arteries Arthritis Asthma Bladder Blood Transfusion Bowel Breasts Pain Cancer Coronary Artery Disease Depression Diabetes Gall Bladder Heart Attack High Blood Pressure Kidney Problems Lymph Nodes Prostate Skin Stomach Thyroid Vein or Blood Clot

Pain, Where? Explain:

Other:

Family History: (Please check any that are problems for immediate family)

M=Mother F=Father S=Sibling G=Grandparent

Abnormal Bleeding Anesthesia Complications Back Pain Cancer Depression Diabetes Genetic Disorder Heart Disease Hepatitis High Blood Pressure High Cholesterol Lung Disease Lupus Neck Pain Osteoporosis Rheumatoid Arthritis Seizure Suicide

Other:

Social History

Married? Yes No

Children? Yes No

Smoker? Current: Yes No Past: Yes No

If yes, how many a day? How many years? How long ago?

Alcohol Consumption? Yes No Amount/Week

Exercise? Yes No Times/Week Type of Exercise

Chemical Dependency/Drug addiction? (Please check one) Current Past

If past, number of years drug free:

Patient/Family Teaching Record

Patient's Name:

D.O.B. MR Number:

1. What is your primary language

2. How do you feel most comfortable learning Orally Visually (Reading) Other

3. Do you have any physical factors that affect learning?

NONE Vision Hearing Language Cognitive Other

4. Do you have any religious and/or cultural considerations regarding teaching/dispensing medical information?

Yes No

Comments:

Outpatient Summary List

Patient Name: MR DOB

A. Known Adverse and Allergic Drug Reactions / Known Allergies

B. Known Significant Medical Diagnosis & Conditions

C. Known Surgical and Invasive Procedures

D. Known Current Medications

E. Providers Initial / Date of Service / No Changes

Patient Registration

Medical Record Number

Name (Last, First, Middle):

Date of Birth:

Address:

Age: Sex:

Race:

Phone: SSN: M. Status:

Employer:

Address:

Occupation: Phone: Ext:

Emergency Contact Name: Next of Kin:

Address: Address:

Relationship: Phone: Relationship: Phone:

Primary Care Physician: Referring Physician:

Address: Address:

Phone: Phone:

Guarantor Name (Bill To): Guarantor's Employer:

Address: Address:

Phone: SSN: Phone:

Primary Carrier

Name: Address:

Subscriber's Name: Subscriber's Employer:

DOB: SSN:

ID / Policy #: Group #:

Effective Date: Expiration Date:

Secondary Carrier

Name: Address:

Subscriber's Name: Subscriber's Employer:

DOB: SSN:

ID / Policy #: Group #:

Effective Date: Expiration Date:

Worker's Compensation If work related injury, please complete this section:

Employer: Injury Date: Case Number:

Case Worker / Contact Name / Phone Number:

Claims Address:

Consent for Treatment, Releases, Acknowledgements and Financial Agreement

By my signature on the front of this form, I agree that I:

1. General Consent for Treatment. Voluntarily consent to and authorize such care and treatments, including diagnostic tests, medical procedures and medications by Georgetown University Hospital.

2. Right to Refuse Treatments. Understand that I have the right to make informed decisions regarding all care and treatments, including the right to refuse any treatments I do not want.

3. Assignment of Benefits / Financial Responsibility. I agree to be responsible for all charges not covered by insurance or other claims.

4. Property Release. Release the Hospital from responsibility for valuables, money, personal or other possessions not properly deposited with the Hospital.

5. Acknowledgment of Receipt of Notice of Privacy Practices. Acknowledge receipt or decline the MedStar Health Notice of Privacy Practices.

For Georgetown University Hospital Use Only

Patient signature / acknowledgement of receipt of Notice of Privacy Practices not obtained because:

Emergency patient Patient / Patient Representative declined to acknowledge Patient / Patient Representative unable / unwilling to acknowledge receipt

GUH Representative:

By Signing below, I acknowledge that I have read, understand and agree to the terms and conditions on this form.

Printed Name of Patient Representative

Relationship to Patient

MRUN PHYSICIAN / OFFICE USE ONLY

Form Reviewed Cards Xeroxed By

Date Keyed D/E Initials