Neuron Medical Corporation is the neurology practice of Liliana Cohen, M.D., Paul Dudley, M.D. and naturopathic medical doctor Kristin Stiles Green, N.M.D. of Thousand Oaks, California. 

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Appointment

What to Bring to the Appointment

  • Your insurance card
  • Physician referral forms if required by insurance
  • A list of current prescriptions and/or over-the-counter medications you are taking, including dose and frequency
  • Pertinent information about your medical and surgical history
  • Any recent x-rays or appropriate records you may have

Insurance and Payment Information

Neuron Medical Corporation is a provider for Medicare and most major insurance plans. We provide insurance billing. Anything not covered by insurance will be your responsibility.

We request payment at the time of your appointment for services that are not covered by insurance. Your insurance company may also require you to pay a co-payment at the time of your appointment. When necessary, our staff will work closely with patients who require a payment plan.

If you have any questions regarding which insurance plans we accept or any patient billing concerns, please call us at the phone number below. Questions regarding your coverage and benefits should be directed to your employer or insurance company.

Hospital Affiliations

Dr. Cohen and Dr. Dudley are affiliated with the following medical facility:

Patient Forms

Click on the following links to download and print our patient forms and send to email neuronoffice@gmail.com, or fill online .

New Patient Forms – Neurology:

    New Patient Information sheet


    The fields marked with * are mandatory


    Date of birth*

    RESPONSIBLE PARTY, SIGNIFICANT “OTHER” OR SPOUSE INFORMATION

    INSURANCE INFORMATION

    PHARMACY INFORMATION

    I hereby assign, transfer and set over to Neuron Medical Corp. all of my rights, title and interest to my medical reimbursement benefits under my insurance policy. I authorize the release of any medical information needed to determine these benefits. This authorization shall remain valid until written notice is given by me revoking said authorization. I understand that I am financially responsible for all charges whether or not they are covered by insurance. A $50.00 cancellation fee will be charged to any and all patients who do not cancel their appointment within 24 hours prior to their scheduled appointments.

    Date of completion*

    The fields marked with * are mandatory

      Neurology Patient History Form

      PATIENT DATA


      (If you are here for a return visit, you may complete only side one if other information is unchanged.)

      1.Please describe the problem that prompted your appointment and your goals for this visit.

      2. Please supply the following information:

      I am:

        right-handed

       

       

      3.Please neatly write your current medications (include dose size and number of times a day taken).

      Daily Medications: As needed, Herbal or OTC meds Allergies:

      4.Which symptoms have you experienced in the last month? Please check all that apply

      REVIEW OF SYSTEMS
        Abdominal pain   Double vision   Ringing in ears
       Back pain  Fatigue  Shortness of breath
        Blood in urine   Faintness   Sinus congestion
        Bruise easily   Headache   Sleep problems
        Burning with urination   Heart palpitations   Snoring
        Chest Pain   Heartburn   Teeth or gum problems
        Chest Pressure   Joint pain   Tremors
        Chills   Memory loss   Urinary frequency
        Constipation   Muscle pain   Incontinence
        Cough,chronic   Muscle tenderness  Vision disturbance or change
        Depression  Nausea  Weakness
        Diarrhea   Vomiting   Weight gain
        Difficulty with swallowing   Neck pain   Weight loss, trying
        Dizziness   Panic attack   Not trying
          Rash  

      5.If you have headaches, back pain or other pain, please complete the following section

        Check here if you do not have a problem with pain.

      PAIN ASSESSMENT
      Location of pain Radiation (where does pain move):
      Duration (how long does pain last):
      Severity − How bad is the pain on a 1-10 scale, with 10 the worst pain you can imagine: / 10  
      Timing – pain occurs most:  morning;   afternoon; evening; night;   any time;  wakes me from sleep
      Quality:   dull;   stabbing;   sharp;   burning;   throbbing;
       other (describe):
      Recent change – pain is: worse;   better;     more frequent;  less frequent;    no recent change;
        I am taking pain meds;   I am using a pain control strategy.
      Current therapy is:   working well;    not working.
      6.MEDICAL HISTORY (Check and write the year this was diagnosed)  
      Alcoholism Headaches Seizures, epilepsy
      Angina Hypertension(High blood pressure) Seizures, nonepileptic
      Anxiety Hyperthyroidism Shingles
      Arthritis Hypothyroidism Sinusitis
      Asthma Infertility Skin cancer
      Bowel problems Kidney problems Systemic Lupus rythematosus
      Cancer: Type Kidney stones Sleep apnea
      Cardiac Arrhythmias (A-fib) Lipid disorders, high cholesterol Stroke TIA (mini-stroke)
      Cardiac disease(heart disease) Liver conditions Syncope (fainting)
      COPD, emphysema Meningitis Tremor
      Dementia Multiple sclerosis Ulcer
      Depression Myopathy (muscle disease) Uterine: Endometriosis
      Diabetes mellitus Neuropathy Fibroids
      Fibromyalgia Gastritis or GERD Parkinson’s Disease
          Trauma/accident
      Other:    
      Other:    
      7.PRIOR SURGICAL PROCEDURES (Check and write the year of the surgery)
      Back surgery Laparoscopy
      Brain surgery Mastectomy
      CABG, Coronary artery bypass (Heart bypass) Neck surgery
      Carotid endarterectomy: Right; Left; Sinus surgery
      Cataract surgery Spine surgery
      Cholecystectomy Tonsillectomy and adenoids
      C-section Tubal ligation
      Hysterectomy / Ovaries removed also TURP, prostate surgery
      Hip surgery / Knee surgery    
      Other:

      8.Which of these tests have you had? Please check appropriate boxes.

      MEDICAL EVALUATIONS (check the place and date of the test)
      MRI EEG Carotid Doppler
      CT EMG/NCS Echocardiographph

      9.Please check appropriate boxes

      SOCIAL HISTORY

      I am DISABLED; RETIRED

      Marital Status: SINGLE; MARRIED; DIVORCED; SEPARATED; WIDOWED;

      Habits:

      caffeine:

      smoking

      alcohol: drug use;  

      Education: some High School; HS Diploma; College

      Graduate/Professional School

      ABUSE SCREEN: Have you suffered emotional, physical or sexual abuse?

      10.Which of these diseases run in your family? Please mark with "x" all that apply.

      FAMILY HISTORY (list the relative involved next to the diagnosis)
      Alcoholism Domestic violence Multiple sclerosis
      Alzheimer’s Drug abuse Neuropathy
      Brain Aneurysms Elevated cholesterol Parkinson’s
      Cancer Heart disease
      Schizophrenia
      Depression High blood pressure Seizures
      Diabetes mellitus Migraine Stroke

      Father:

      Mother:

      Siblings:




      New  Patient Forms – Naturopathic Medicine / Dr. Green:

        New Patient Information sheet


        The fields marked with * are mandatory


        Date of birth*

        RESPONSIBLE PARTY, SIGNIFICANT “OTHER” OR SPOUSE INFORMATION

        INSURANCE INFORMATION

        PHARMACY INFORMATION

        I hereby assign, transfer and set over to Neuron Medical Corp. all of my rights, title and interest to my medical reimbursement benefits under my insurance policy. I authorize the release of any medical information needed to determine these benefits. This authorization shall remain valid until written notice is given by me revoking said authorization. I understand that I am financially responsible for all charges whether or not they are covered by insurance. A $50.00 cancellation fee will be charged to any and all patients who do not cancel their appointment within 24 hours prior to their scheduled appointments.

        Date of completion*

        Other Forms and Documents: