Patient history form The fields marked with * are mandatory Neurology Patient History Form PATIENT DATA Date of birth* Date (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. Chief complaint 2. Please supply the following information: Age* Gender* —Please choose an option— male female I am: ☒ right-handed ☒ left-handed ☒; ambidextrous 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 since: 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: Send Form

Patient Information | Neuron Medical | Thousand Oaks CA | Neuron Medical Corporation

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

Schedule an Appointment

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.

Payment

Pay a bill online

Please click the button below to pay an invoice via USPAY Gateway secure online payment screens.

You will need the patient’s name and date of birth, and the bill ID (please ensure that this is entered exactly)

Pay online

Hospital Affiliations

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

Los Robles Hospital & Medical Center, Thousand Oaks, CA

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

New Patient Information sheet

New Patient Information sheet

The fields marked with * are mandatory

First Name

Middle Name

Last Name

Date of birth

Sex

Marital status

Address

Address (street)

City

State

Zip Code

Mobile Ph #

Cell#:

Driver lic. Or ID#

Employer name and address

Referring physician:

RESPONSIBLE PARTY, SIGNIFICANT “OTHER” OR SPOUSE INFORMATION

Name

Relationship to patient

Address (street)

City

State

Zip Code

Phone #

Driver lic. Or ID#

Work #

Employer name/address

Friend or relative not living with you

Phone#

INSURANCE INFORMATION

Medicare #

Insurance Company:

Insured’s Name

Relationship to patient

INSURANCE INFORMATION

Preferred Pharmacy:

Phone#:

Address:

I Agree to Terms:

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.

Patient’s signature

Date of completion

Patient history form

Patient history form

The fields marked with * are mandatory

Neurology Patient History Form

PATIENT DATA

Date of birth*

Date

(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.

Chief complaint

2. Please supply the following information:

Age*

Gender*

I am:

☒ right-handed

☒ left-handed

☒; ambidextrous

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 since:
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:

Medication/Supplement Record

Medication/Supplement Record

Arbitration contract - English

Arbitration contract – English

PHYSICIAN-PATIENT ARBITRATION AGREEMENT ENGLISH

PHYSICIAN-PATIENT ARBITRATION AGREEMENT

Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

Article 2: All Claims Must Be Arbitrated: It is the intention of the parties that this agreement shall cover all claims or controversies whether in tort, contract or otherwise, and shall bind all parties whose claims may arise out of or in any way relate to treatment or services provided or not provided by the below identified physician, medical group or association, their partners, associates, associations, corporations, partnerships, employees, agents, clinics, and/or providers (hereinafter collectively referred to as “Physician”) to a patient, including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term “patient” herein shall mean both the mother and the mother’s expected child or children.
Filing by Physician of any action in any court by the physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim. However, following the assertion of any claim against Physician, any fee dispute, whether or not the subject of any existing court action, shall also be resolved by arbitration.

Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing by U.S. mail, postage prepaid, to all parties, describing the claim against Physician, the amount of damages sought, and the names, addresses and telephone numbers of the patient, and (if applicable) his/her attorney. The parties shall thereafter select a neutral arbitrator who was previously a California superior court judge, to preside over the matter. Both parties shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the arbitrator. Patient shall pursue his/her claims with reasonable diligence, and the arbitration shall be governed pursuant to Code of Civil Procedure §§ 1280-1295 and the Federal Arbitration Act (9 U.S.C. §§ 1-4). The parties shall bear their own costs, fees and expenses, along with a pro rata share of the neutral arbitrator’s fees and expenses.

Article 4: Retroactive Effect: The patient intends this agreement to cover all services rendered by Physician not only after the date it is signed (including, but not limited to, emergency treatment), but also before it was signed as well.

Article 5: Revocation: This agreement may be revoked by written notice delivered to Physician within 30 days of signature and if not revoked will govern all medical services received by the patient.

Article 6: Severability Provision: In the event any provision(s) of this Agreement is declared void and/or unenforceable, such provision(s) shall be deemed severed therefrom and the remainder of the Agreement enforced in accordance with California law.

I understand that I have the right to receive a copy of this agreement. By my signature below, I acknowledge that I have received a copy.

NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HA VE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE I OF THIS CONTRACT.

Print Patient’s Name

Date

Print Name and Relationship to Patient (if applicable)

Date

A signed copy of this document should be given to the patient. The original copy will be archived in the patient’s medical file.

Arbitration contract - Spanish

Arbitration contract – English

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CONTACTS

Appointment

What to Bring to the Appointment

Insurance and Payment Information

Payment

Pay a bill online

Hospital Affiliations

Patient Forms

New Patient Forms – Neurology:

New Patient Information sheet

RESPONSIBLE PARTY, SIGNIFICANT “OTHER” OR SPOUSE INFORMATION

INSURANCE INFORMATION

INSURANCE INFORMATION

The fields marked with * are mandatory

Neurology Patient History Form

New Patient Forms – Naturopathic Medicine / Dr. Green:

New Patient Information sheet

RESPONSIBLE PARTY, SIGNIFICANT “OTHER” OR SPOUSE INFORMATION

INSURANCE INFORMATION

INSURANCE INFORMATION

Other Forms and Documents:

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