Dr. Barkodar Intake Form
Name
*
First Name
Last Name
Birth Date
*
-
Month
-
Day
Year
Date
Gender
Female
Male
Other
Email
example@example.com
Cell Phone Number
Home Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Information
*
Where may we leave medical information?
*
cell phone
home phone
emergency contact
Other
Insurance Provider or Method of Payment
Insurance Card (Front)
Insurance Card (back)
ID/drivers license (front)
ID/drivers license (back)
Main Reason For Your Visit
Is this related to any legal actions?
No
Yes and I have an attorney
Yes but I do not have an attorney
Check all symptoms that apply
Headache
Sound Sensitivity
Light sensitivity
Tremor
Weakness in Arm
Weakness in Leg
Falls
Imbalance
Numbness
Tingling
Incontinence (cant control bladder or bowel movements)
Difficulty concentrating
Lightheadedness
Spinning
Hearing loss
Memory issues
Irritability/outbursts of anger
Weight gain/loss
Dizziness
Sleep disturbance
Vision changes ( MUST SEE OPHTHALMOLOGIST IF NOT RECENTLY SEEN)
Head Injury
Neck pain
Heart palpitations
Neck pain that goes into arms
Shortness of breath
Back pain
Feeling dizzy/lightheaded
Back pain that goes into legs
Nausea
Vomiting
Thoughts of Suicide
Homicidal Ideation
Ringing in ears
Chest Pain
Other
Existing Medical Conditions
High blood pressue
Cholesterol issues
Diabetes
Cancer
Migraines
Dementia
Parkinsons
Multiple Sclerosis
Other
List any other chronic health problems you may have
List any surgeries you have had
List out all current medication
List out allergies
Are you on blood thinners?
No
Aspirin
Plavix
Coumadin or Warfarin
Eliquis
Xarelto
Other
Please select the option that apply regarding your smoking habits
None
0 -1 package a day
1 - 2 packages a day
2+ packages a day
Average # alcoholic drinks per week?
Any Recreation Drug Use and if so what type?
Average hour of sleep per week?
Any Family History of the Following Conditions
Dementia
Migraine
Seizures
Brain Tumor
Multiple Sclerosis
Neuropathy
Tremor
Parkinsons
Other
By Signing Here You Give Authorization For Dr. Barkodar To Obtain Any and All Health and Medical Records:
INSURANCE: Although we will try to verify your insurance, our staff cannot guarantee your coverage. It is your responsibility to check about services and providers before your appointment.
*
Cancellation later than 48 hours in advance will be charged a $40 fee; Returned checks will be charged a $25 fee.
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I AUTHORIZE LEON BARKODAR, M.D. TO FURNISH TO THE INSURANCE COMPANIES ALL INFORMATION WHICH THE INSURANCE COMPANIES MAY REQUEST. I ASSIGN DR. BARKODAR ALL BASIC AND MAJOR MEDICAL BENEFITS RELATED TO THE SERVICES RENDERED. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR CHARGES NOT COVERED BY THE INSURANCE COMPANIES.
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Date
-
Month
-
Day
Year
Date
The Above Form Is True to the Best of My knowledge Signature
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