Narendra Kansal, MD - Publicforms

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APPOINTMENT REQUEST BACK OR LEG DISABILITY FORM HIPPA NOTICE/ CONSENT FORM MEDICATION REFILL REQUEST NECK DISABILITY FORM NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW ASSIGNMENT OF BENEFITS FORM NO FAULT CLAIMANT HISTORY FORM NO FAULT INFORMATION SHEET PATIENT INFORMATION PART 2 PATIENT INFORMATION SHEET 1 RECORDS RELEASE FORM REVIEW OF SYSTEMS Welcome to our Neurosurgery practice. WORKERS COMPENSATION INFORMATION SHEET

PATIENT INFORMATION PART 2

NAME *

MEDICAL INFORMATION

PLEASE DO NOT LEAVE ANY BLANK SPACES; IF SOMETHING DOES NOT APPLY PUT N/A IN THE SPACE PROVIDED.

DO YOU OR HAVE YOU EVER HAD:

DIABETES *

YES

HEART DISEASE *

YES

ARTHRITIS *

YES

LUNG PROBLEMS *

YES

KIDNEY DISEASE *

YES

HIGH BLOOD PRESSURE *

YES

CANCER *

YES

THYROID *

YES

OTHER

HEIGHT *

WEIGHT *

DO YOU HAVE ANY ALLERGIES TO:

FOOD: *

IF NO, WRITE N/A

DRUGS *

IF NO, WRITE N/A

IODINE *

IF NO, WRITE N/A

ANY OTHER ALLERGIES?

DO YOU CURRENTLY SMOKE? *

YES

IF YES, HOW MANY PER DAY? *

IF NO, PUT N/A

FOR HOW MANY YEARS? *

IN NO, PUT N/A

HAVE YOU EVER SMOKED? *

YES

IF YES, HOW MANY PER DAY?

WHEN DID YOU QUIT?

HOW LONG DID YOU SMOKE FOR?

DO YOU SMOKE CIGAR?

YES

DO YOU SMOKE PIPE?

YES

DO YOU CHEW TOBACCO?

YES

DO YOU DRINK ALCOHOLIC BEVERAGES? *

YES

IF YES, HOW MUCH/HOW OFTEN? *

IF NO, PUT N/A

HAVE YOU BEEN TREATED FOR DEPRESSION? *

YES

OR PSYCHOLOGICAL PROBLEMS? *

YES

MEDICATIONS

PLEASE LIST ALL MEDICATIONS WITH THE DOSE YOU TAKE *

ARE YOU CURRENTLY TAKING ANY ANTI-INFLAMMATORY MEDICATIONS AND/OR ASPIRIN?

IF YES, WHAT AND FOR HOW LONG?

DESCRIBE THE MEDICAL PROBLEM THAT BRINGS YOU TO OUR OFFICE *

HAVE YOU BEEN SEEN BY OTHER ORTHOPEDIC OR NEUROSURGEONS? *

YES

IF YES, WHO?

DATE LAST SEEN?

REASON?

HAVE YOU BEEN SEE BY A NEUROLOGIST? *

YES

IF YES, REASON?

ANY PAST SURGERIES? *

FAMILY MEDICAL HISTORY

MOTHER IS: *

ALIVE

DECEASED

IF DECEASED, AGE AND OF WHAT? *

IF ALIVE, PUT N/A

FATHER IS: *

ALIVE

DECEASED

IF DECEASED, AGE AND OF WHAT? *

IF ALIVE, PUT N/A

AGE OF SIBLINGS AND ANY MEDICAL PROBLEMS: *

Please list your siblings age and any medical problems they may have. If you do not have any siblings, please put NA, if a brother or sister is deceased, please put at what age and of what.

* Required field