I don't think it has much diagnostic value, but I thought it was worth saving nonetheless
To streamline patient visits, it appears that an increasing number of neurologists will be moving toward this standardized form:
Quote:
Neurology Partners, LLC.
Streamlined Patient History
SECTION I
VITAL STATISTICS
PLEASE ANSWER EVERY QUESTION IN THIS SECTION. THIS INFORMATION IS ESSENTIAL TO YOUR TREATMENT.
Insurance Company:____________________
Policy Number:________________________
Visa:_____________________Expiration __/__/____
MasterCard:_______________ Expiration __/__/____
Discover:_________________Expiration __/__/____
Diners:___________________Expiration __/__/____
Checking Account Number:______________
Savings Account Number:______________
IRA Account Number:______________
Other Investments:______________
Annual Income:________________
Spouse’s Annual Income:________________
Home Mortgage ID Number: __________
Car Make & Model:_____________ Blue Book Value:_____
Cash in Pocket Today: $_____________
(Include change)
SECTION II
PATIENT COMPLAINTS AND QUESTIONS
DESCRIBE YOUR SYMPTOMS IN DETAIL.
Use a separate piece of paper. Discard.
LIST ALL OF YOUR QUESTIONS INSIDE THIS BOX: > [ ]
Please print clearly using large capital letters.
IF YOU HAVE RESEARCH YOU WOULD LIKE US TO READ:
Please leave it in the blue bin by the door marked “Paper Only. No Glass or Plastic.”
SECTION III
DIAGNOSIS
For use by your doctor, RN, or the fax machine girl.
[ ] You have ALS. Unfortunately, I can offer you no treatment for this condition.
[ ] You have MS. Unfortunately, I can offer you no treatment for this condition.
[ ] You have Parkinson’s. Unfortunately, I can offer you no treatment for this condition.
[ ] You have Alzheimer’s. Unfortunately, I can offer you no treatment for this condition.
[ ] You have Peripheral Neuropathy. Unfortunately, I can offer you no treatment for this condition.
[ ] You have Small Fiber Peripheral Neuropathy. Unfortunately, I don’t know what that is.
SECTION IV
CONTACTING YOUR DOCTOR
If you would like to speak with your doctor, call (617) 555-5555 and leave a message for Lisa. Please speak clearly and slowly, as she does not speak a word of English. You will be contacted as soon as your credit card expires.
Thank you for visiting Neurology Partners. We hope your visit was as profitable for you as it has been for us. Even though that’s not too likely.
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