Todays date*

PCP:

Referring Physician

Patients name

Patient Full Name*:

Mr.

Mrs.

Miss

Ms.

Marital status

Single

Married

Divorced

Separated

Widowed

Former name

Home Phone

Work Phone

Cell Phone

Sex

Male

Female

Mailing address*

Social Security no*

Birth date*

Age

P.O. box

City

State

ZIP Code

Email

Employer

Employer Address

Employer phone no

Who should we contact in an emergency?

Full Name

Phone number

INSURANCE INFORMATION REQUIRED

Make sure to bring all insurance cards with you to the appointment.
Please avoid using skin creams, lotions and moisturizers on your arms and legs 24 hours prior to your appointment.

YOUR RESULTS WILL BE SENT TO THE REFERRING PHYSICIAN. FOR ANY ADDITIONAL PHYSICIANS/TREATING PERSONNEL, PLEASE LIST THEIR INFORMATION BELOW.

Dr

Phone

Fax

Dr

Phone

Fax

Dr

Phone

Fax

Dr

Phone

Fax

Dr

Phone

Fax

Date of Birth

Is your visit due to a WORK-RELATED INJURY?

Yes

No

If yes, Date

State it occurred in.

Is your visit due to a Motor Vehicle Accident?

Yes

No

If yes, Date

State it occurred in.

Is your visit due to a Personal Injury Case?

Yes

No

If yes, Date

State it occurred in.

Do you have an Attorney

Yes

No

If yes, Name

Phone

IF NO, GIVE THE FRONT DESK YOUR INSURANCE CARD(S) AND ENTER THE FOLLOWING:
(* Required if you are not subscriber)

PRIMARY INSURANCE

ID#

Group#

Subscriber Name

If PATIENT is not the subscriber, List subscriber D.O.B. and your relation to subscriber below

DOB

Relationship to subscriber

SECONDARY INSURANCE

ID#

Group#

Subscriber Name

If PATIENT is not the subscriber, List subscriber D.O.B. and your relation to subscriber below

DOB

Relationship to subscriber

TERTIARY INSURANCE

ID#

Group#

Subscriber Name

If PATIENT is not the subscriber, List subscriber D.O.B. and your relation to subscriber below

DOB

Relationship to subscriber

If you are a child of the subscriber, who is financially responsible for deductibles, coinsurance, and copays.

NAME

ADDRESS

FAILURE TO GIVE THE CORRECT INFORMATION PRIOR TO TESTING WILL RESULT IN UNNECESSARY OUT- OF- POCKET COST FOR YOU (THE PATIENT).

I understand that NEUROLOGICAL AND ELECTRODIAGNOSTIC INSTITUTE OF ST. LOUIS, INC (the “Practice) has certain rights and obligations with regard to my protected health information (information regarding my health and treatment that the Practice may have in its possession). I also understand that I have certain rights with regard to my protected health information.

I authorize the Practice to provide informational reminders regarding upcoming appointments I may have to me or anyone who may answer the telephone, or to leave such reminders on any telephone answering device or service, at the telephone number(s) I have provided the Practice as telephone numbers at which I may be contacted (other than the telephone number of my place of employment). I authorize my records to be sent to me and only me at the address I provide on my registration form (upon request). I understand at the time of request if my address is not the same as listed a new release will be required.

I authorize the Practice to disclose my protected health information to any of the following persons (state name of person and relationship to you):

I understand that I may revoke any authorization granted above by written notice signed by me delivered to the Practice’s Privacy Official at the address stated below. My authorization remains valid until revoked by me in writing.

I acknowledge receipt of the Practice’s Privacy Practices Notice effective September 23, 2013 regarding the Practice’s rights and obligations and my rights regarding my Protected Health Information. I acknowledge that I understand that I have the right to request and receive clarifications, explanations or further information with regard to The Practice’s Privacy Practices through written request signed by me addressed to the Practice’s Privacy Official.

Neurological and Electrodiagnostic Institute of St. Louis, Inc
Attn: Privacy Official
14825 North Outer 40
Suite 330
Chesterfield, MO 63017

Todays Date

Full Name

Date

To ensure you receive a complete and thorough consultation, please provide us with important background information on the following form. If you do not understand the question, our receptionist will assist you.
Thank you.

HISTORY OF PRESENT CONDITION

1. What are your symptoms?

Please note areas of pain.

2. When did your symptoms begin? (Please indicate a specific date if possible)

3. Was the onset of this episode gradual or sudden?

Gradual

Sudden

4. Which of the following best describes how your symptoms occurred? (if your condition is post-surgical please indicate as per original injury)

Lifting

A MVA (car accident)

A Fall

Overuse

Trauma

Degenerative process

During recreation sports

Throwing

Incident at work

Unknown

Other

Which?

5. Since onset, are your symptoms getting: (check one)

Better

Worse

Not changing

6. Have you had similar symptoms in the past?

Yes

No

More than one episode?

Yes

No

7. Nature of pain/symptoms (check all that apply)

Sharp

Dull

Throbbing

Aching

Occasional

Constant

Other

Which?

8. As the day progresses, do your symptoms: (Check one)

Increase

Decrease

Stay the same

9. Does the pain wake you at night?

No

Yes

10. Do you have pain/stiffness/numbness/tingling upon getting out of bed in the morning?

Yes

No

11. Since the onset of your current symptoms have you had:

Any difficulty with control of bowel or bladder function

Numbness

Any dizziness or fainting attacks

Weakness

Unexplained weight change

Night pain / sweats

Malaise (vague feeling of bodily discomfort)

12 What aggravates your symptoms?

13. What relieves your symptoms?

14. Have you had any of the following tests?Indicate when and where:

None

Nerve conduction/EMG

X-rays

CT Scan

MRI Scan

Arthrogram

Myelogram

Bone Scan

Epidural Steroid Injection

Selective Nerve Block

Trigger point injections

Chiropractic Manipulations

Sympethectomy

Rhizotomy

Other

Which?

Where was the test performed and when

Are you:

Left handed

Right handed

Current weight

Current height

PATIENT QUESTIONNAIRE/HEALTH HISTORY

Past Medical History: (please check any conditions you have or have had in the past)

High Blood Pressure

Low Blood Pressure

Diabetes- years?

Asthma

Shortness of Breath

Emphysema

Chronic Cough

Tuberculosis

Coronary Artery Disease

Paralysis

Herniated Disc in Neck / Back

Peripheral Neuropathy

Angina

Cardiac Arrhythmia/A-Fib

Heart Attack

Congestive Heart Failure

Mitral Valve Prolapse

Blood Clots

Anemia

Bleeding Problems

Stroke

Spinal Fracture

Spinal Stenosis

Peripheral Vascular Disease

Seizures

Multiple Sclerosis

Parkinson's Disease

Thyroid Disease

Kidney Disease

Liver Disease

Hepatitis A, B, or C

Irritable Bowel Syndrome

Gastritis/Peptic Ulcer Disease

Back Pain/ Back Injury

Neck Pain/Neck Injury

Cancer-Type

GI Bleeding

Constipation

Enlarged Prostate/Urinary Retentione

Endometriosis

HIV

Osteopenia/Osteoporosis

Arthritis (Hip, Knee, Shoulder)

Fibromyalgia

Head Injury

Numbness in Hands

Numbness in Feet

Other

FAMILY HISTORY:

(Check those that apply)

Heart Disease/MI

Mom

Dad

Sibling

High Blood Pressure

Mom

Dad

Sibling

Stroke

Mom

Dad

Sibling

Cancer

Type

Mom

Dad

Sibling

Diabetes

Mom

Dad

Sibling

Asthma

Mom

Dad

Sibling

Seizures

Mom

Dad

Sibling

Bleeding Disorder

Mom

Dad

Sibling

Thyroid Disease

Mom

Dad

Sibling

Kidney Disease

Mom

Dad

Sibling

Mental Illness

Mom

Dad

Sibling

Acid Reflux/Ulcer

Mom

Dad

Sibling

Unknown

Mom

Dad

Sibling

Other

Mom

Dad

Sibling

Are there any medical diseases conditions or problems that run in the family? Yes or No If yes, please tell us what they are and your relation to the person. (DO NOT WRITE NAMES)

SOCIAL AND PERSONAL HISTORY:

Do you smoke?

Yes

No

Packs per day

Years:

If you smoked and quit,

Date:

How long did you smoke?

Years:

Do you drink alcohol?

Yes

No

Drinks per week

If you drank and quit when did you quit?

Have you ever had a problem with drugs or alcohol?

Are you:

Single

Married

Divorced

Separated

Widowed

Current living arrangement

Live alone

Spouse

Roommate

Parents

Significant other

Level of Education

Where do you work and in what status? (If retired, list most recent place of employment and date of retirement)

List ALL SURGERIES you have had in the past with approximate dates indicating if the surgery was done on the left or right side if applicable.

1

2

3

4

5

6

Please list ALL CURRENT MEDICATIONS

MEDICATION

Dosage

Frequency

Route of Admin

MEDICATION

Dosage

Frequency

Route of Admin

MEDICATION

Dosage

Frequency

Route of Admin

MEDICATION

Dosage

Frequency

Route of Admin

MEDICATION

Dosage

Frequency

Route of Admin

MEDICATION

Dosage

Frequency

Route of Admin

MEDICATION

Dosage

Frequency

Route of Admin

MEDICATION

Dosage

Frequency

Route of Admin

MEDICATION

Dosage

Frequency

Route of Admin

MEDICATION

Dosage

Frequency

Route of Admin

(If needed please ask for an additional list)

ALLERGIES

DRUG ALLERGIES

Are you currently taking any of the following over the counter medications?

Aspirin

Tylenol

Steroids

Antihistamines

Vitamins

Advil

Coumadin

Other

PATIENT QUESTIONNAIRE/HEALTH HISTORY

Review of Systems: Please review the following symptoms and check "Yes" or "No" based on your current or recent symptoms. Please list any other conditions that have not been included. Please follow up with your referring physician regarding any positives from the list below.

Constitutional

Fever

Yes

No

Chills

Yes

No

Loss of appetite

Yes

No

Night Sweats

Yes

No

Excessive weight gain

Yes

No

Excessive weight loss

Yes

No

Malaise

Yes

No

Excessive sleepiness

Yes

No

Unable to sleep

Yes

No

Other condition list

Neurological

Headache

Yes

No

Tremors

Yes

No

Numbness in the feet/legs

Yes

No

Numbness in the arms/hands

Yes

No

Weakness in the legs

Yes

No

Weakness in the arms

Yes

No

Trouble walking

Yes

No

Poor balance

Yes

No

Falls

Yes

No

Loss of consciousness

Yes

No

Seizures

Yes

No

Loss of memory

Yes

No

Confusion

Yes

No

Difficulty in speech

Yes

No

Trouble chewing

Yes

No

Trouble swallowing

Yes

No

Vertigo

Yes

No

Concussion

Yes

No

Other condition list

Cardiovascular

Chest pain

Yes

No

Palpitations

Yes

No

Shortness of breath at rest

Yes

No

Shortness of breath on lying flat

Yes

No

Leg swelling

Yes

No

Syncope/fainting spells

Yes

No

Heart murmurs

Yes

No

Heart failure

Yes

No

High blood pressure

Yes

No

Low blood pressure

Yes

No

Other condition list

Eyes

Double vision

Yes

No

Loss of vision

Yes

No

Decreased vision in the eyes

Yes

No

Glaucoma

Yes

No

Other condition list

Respiratory

Cough

Yes

No

Wheezing

Yes

No

Blood in sputum

Yes

No

Shortness of breath

Yes

No

Other condition list

Musculoskeletal

Back pain

Yes

No

Neck pain

Yes

No

Muscle weakness

Yes

No

Muscle pain (myalgia)

Yes

No

Fatigue

Yes

No

Muscle wasting

Yes

No

Muscular cramps

Yes

No

Joint pains

Yes

No

Joint swelling

Yes

No

Joint stiffness

Yes

No

Other condition list

Endocrine

Diabetes

Yes

No

Thyroid disease

Yes

No

Excessive thirst (polydipsia)

Yes

No

Heat intolerance

Yes

No

Cold intolerance

Yes

No

Sexual dysfunction

Yes

No

Other condition list

Ear/Nose/Throat

Ringing in the ears (tinnitus)

Yes

No

Dizziness

Yes

No

Vertigo

Yes

No

Loss of smell (anosmia)

Yes

No

Loss of taste (aguesia)

Yes

No

Hoarseness of voice

Yes

No

Decreased hearing/deafness

Yes

No

Sores in mouth

Yes

No

Other condition list

Hematological

Unusual bleeding

Yes

No

Sickle cell disease

Yes

No

Other condition list

Gastrointestinal

Loss of bowel control

Yes

No

Rectal bleeding

Yes

No

Jaundice

Yes

No

Gastric ulcer

Yes

No

Gastric bleeding

Yes

No

Hepatitis

Yes

No

Pancreatitis

Yes

No

Other condition list

Genitourinary

Loss of urine control

Yes

No

Urinary urgency

Yes

No

Blood in urine

Yes

No

Dark-colored urine

Yes

No

Kidney stones

Yes

No

Impotence

Yes

No

Sexually-transmitted disease

Yes

No

Other condition list

Skin

Rash

Yes

No

Itching (pruritus)

Yes

No

Photosensitivity

Yes

No

Tumors

Yes

No

Abnormal loss of hair

Yes

No

Pitting on the nails

Yes

No

Other condition list

Allergy

Frequent infections

Yes

No

Other condition list

Others:

Todays date

E-Signature

Please sign electronically below.

NEI OF ST LOUIS, INC. REGISTRATION FORM

INSURANCE INFORMATION REQUIRED

YOUR RESULTS WILL BE SENT TO THE REFERRING PHYSICIAN. FOR ANY ADDITIONAL PHYSICIANS/TREATING PERSONNEL, PLEASE LIST THEIR INFORMATION BELOW.

BILLING INFORMATION

IF NO, GIVE THE FRONT DESK YOUR INSURANCE CARD(S) AND ENTER THE FOLLOWING:
(* Required if you are not subscriber)

FAILURE TO GIVE THE CORRECT INFORMATION PRIOR TO TESTING WILL RESULT IN UNNECESSARY OUT- OF- POCKET COST FOR YOU (THE PATIENT).

AUTHORIZATION FOR RELEASE OF INFORMATION NEUROLOGICAL AND ELECTRODIAGNOSTIC INSTITUTE OF ST. LOUIS, INC

PATIENT QUESTIONNAIRE/HEALTH HISTORY

HISTORY OF PRESENT CONDITION

PATIENT QUESTIONNAIRE/HEALTH HISTORY

FAMILY HISTORY:

SOCIAL AND PERSONAL HISTORY:

Please list ALL CURRENT MEDICATIONS

PATIENT QUESTIONNAIRE/HEALTH HISTORY

Constitutional

Neurological

Cardiovascular

Eyes

Respiratory

Musculoskeletal

Endocrine

Ear/Nose/Throat

Hematological

Gastrointestinal

Genitourinary

Skin

Allergy

Quick checklist

Do you have any of the following?

E-Signature

NEI OF ST LOUIS, INC. REGISTRATION FORM

INSURANCE INFORMATION REQUIRED

YOUR RESULTS WILL BE SENT TO THE REFERRING PHYSICIAN. FOR ANY ADDITIONAL PHYSICIANS/TREATING PERSONNEL, PLEASE LIST THEIR INFORMATION BELOW.

BILLING INFORMATION

IF NO, GIVE THE FRONT DESK YOUR INSURANCE CARD(S) AND ENTER THE FOLLOWING: (* Required if you are not subscriber)

FAILURE TO GIVE THE CORRECT INFORMATION PRIOR TO TESTING WILL RESULT IN UNNECESSARY OUT- OF- POCKET COST FOR YOU (THE PATIENT).

AUTHORIZATION FOR RELEASE OF INFORMATION NEUROLOGICAL AND ELECTRODIAGNOSTIC INSTITUTE OF ST. LOUIS, INC

PATIENT QUESTIONNAIRE/HEALTH HISTORY

HISTORY OF PRESENT CONDITION

PATIENT QUESTIONNAIRE/HEALTH HISTORY

FAMILY HISTORY:

SOCIAL AND PERSONAL HISTORY:

Please list ALL CURRENT MEDICATIONS

PATIENT QUESTIONNAIRE/HEALTH HISTORY

Constitutional

Neurological

Cardiovascular

Eyes

Respiratory

Musculoskeletal

Endocrine

Ear/Nose/Throat

Hematological

Gastrointestinal

Genitourinary

Skin

Allergy

Quick checklist

Do you have any of the following?

E-Signature

IF NO, GIVE THE FRONT DESK YOUR INSURANCE CARD(S) AND ENTER THE FOLLOWING:
(* Required if you are not subscriber)