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NEW PATIENT FORMUPMC MULTIPLE SCLEROSIS CARE CENTERDr’s Heyman, Zaydan, Xia, Isitan and PA’s Ryan Orie and Kiersten DykstraDear Patient: Please COMPLETE this form and BRING IT WITH YOU to your appointment. It will help us care for you better. Thank you!Name:_________________________Date of birth: __________________________Please circle one: Mr. Mrs. Miss Dr.Marital Status:_________________________Address: _______________________Home Ph #: ___________________________ ________________________Cell Ph #: ______________________________ ________________________Work Ph: ______________________________Your medical insurance company: _________________________________Your pharmaceutical insurance company: ___________________________Emergency Contact:Name: ________________________Relationship: _____________________Address: ______________________Ph #: ________________________ _______________________________________________Referring Physician (Name): ______________________Ph #: ________________________Address __________________________________________________________________________Other Physicians or providers who should receive copies of correspondence:Name: _____________________Ph #: __________________________ Address: ________________________ _________________________ _________________________Pharmacy (local):Name: _______________________________Ph #: _________________________Address: _____________________________Fax #: _________________________ _____________________________ _____________________________Pharmacy (mail order):Name: _______________________________Ph #:__________________________Address: _____________________________Fax #: _________________________ ____________________________________________________________Pharmacy (specialty):Name: _______________________________Ph #: __________________________Address: _____________________________Fax #: __________________________ _____________________________ _____________________________Why did you schedule this appointment?______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________What Health care evaluations and tests have already been done for your diagnosis?Evaluation or Test(Circle Yes or NoBeside Test)Approx DateWhere Was it Done?Normal (N)OrAbnormal? (AN)If abnormal, list detailsMRI- Brain(Most Recent)Yes / NoMRI- Brian(2nd most recent)Yes / NoMRI- Brain(other date)Yes / NoMRI- Cervical SpineYes / NoMRI- Thoracic SpineYes / NoCT SCANYes / NoLumbar Puncture (Spinal Tap)Yes / NoVisual Evoked PotentialsYes / NoMedian (Arm) Sensory Evoked Potential Yes / NoSED rateYes/ NoLyme TestYes/ NoVitamin B12 TestYes/ NoTSHYes / NoANAYes / NoNMO TiterYes / NoCRPYes/ NoACEYes/ NoCPKYes/ NoRFYes/ NoHave you ever taken any of the following medications? (If you have a typed list of your current medications, please attach to this packet.)Medication(Circle Yes or NoStart DateEnd DateReason DiscontinuedInfusions:Mitoxantrone (Novantrone)Yes / NoTysabriYes / NoRituxanYes / NoOcrevusYes / NoIVIGGYes / NoLemtradaYes / NoCytoxanYes / NoOrals:GilenyaYes / NoAubagioYes / NoMethotrexateYes / NoImuran (Azathioprine)Yes / NoCellcept (Mycophenolate)Yes / NoTecfideraYes / NoAmpyraYes / NoMavencladYes / NoMayzentYes / NoInjectables:Medication (Circle Yes or No)Start DateEnd DateReason DiscontinuedBetaseron/ExtaviaYes / NoAvonexYes / NoCopaxone/Glatopa/Glatiramir AcetateYes / NoRebifYes / NoPlegridyYes / NoZinbrytaYes / NoHave you ever received steroids for your neurological problems?Steroid NameDoseOral or IVDates ReceivedPlease list all operations, surgeries, deliveries, and other hospitalizations:Date (Year)Reason for HospitalizationHospital & CitySocial History:Are you right or left handed? ________________What was the highest grade you completed? ____________________Occupation: ___________________________Do you currently use tobacco? YES NO Former user, I quit on: _____________ If yes, how many per day _______________Durable Power of Attorney? ____________*If you answered yes to either of the above, please bring a copy to your appointment.Have you ever been diagnosed or treated for any of the following conditions?Medical ConditionYear of onsetMedical ConditionYear of onsetHigh blood pressure/ hypertensionYes/NoSeizuresYes/NoHigh cholesterol/ fatsYes/ NoLupus or rheumatoid arthritisYes/NoHeart problems (attacks, failure, angina, atrial fibrillation, etc)Yes/ NoBlood clots, thrombosis, embolismYes /NoStroke, ministrokes, TIAsYes/ NoMigraine or headacheYes/ NoCancer or tumors Yes / NoHead injury or concussionYes / NoNervous breakdown, anxiety, depression, “nerves”Yes / NoNeck or back injury, whiplashYes / NoKidney problemsYes/ NoGlaucoma, cataracts, macular degenerationYes/ NoLiver problemsYes/ NoUlcers, gastritis, reflux, colitisYes/ NoLung or breathing problems, asthma, emphysema, bronchitisYes/ NoDiabetes, high blood sugarYes / NoThyroid problemsYes / NoPlease list any additional medical conditions/problems:Medical ConditionYear of onsetMedical ConditionYear of OnsetFamily History:RelationshipAgeLiving/DeceasedHealth Status/ Notable IllnessesMotherFatherSiblingSiblingSiblingSiblingChildrenChildrenChildrenChildrenChildrenDoes anyone in the family have MS? YESNOIf yes, please indicate their relationship to you: _____________________________________________Does anyone in the family have any other autoimmune disorders? YES NOIf yes, please indicate the disorder and the relationship to you:DisorderRelationshipDisorderRelationshipDoes anyone in the family have any other neurological disorders? YESNOIf yes, please indicate the disorder and their relationship to you:DisorderRelationshipDisorderRelationshipCurrent Medications, Injections, & Supplements Taken:Please include any vitamins, supplements, pain relief, cold medication, shots, topical creams/patches, sprays, suppositories, injections, etc. (If you have a typed list of your current medications containing all this information, please skip this section and attach the list.)MedicationPill Size/StrengthHow Many/ How OftenAllergies/Sensitivity:Medication/SubstanceReactionMedication/SubstanceReaction ................
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