NEW Neurology Dr. Barkodar

1
What's your name?* This field is required.
First Name
Middle Name
Last Name
2
Date of Birth* This field is required.
Date
Year
Month
Day
3
Cellphone Number* This field is required.Cellphone Number
Area Code
Phone Number
4
Date of Injuryif unknown leave best estimate
Date
Month
Day
Year
5
Age* This field is required.
6
Sex
7
What is your mailing address?* This field is required.
Street Address
Street Address Line 2
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8
What is your email?* This field is required.
9
Emergency Contact* This field is required.
Name
Phone number
10
Where can we leave Medical Information?* This field is required.Check ALL that apply
Cellphone
Homephone
Spouse
Children
Emergency Contact
Email
Other
11
Other:Please specify
12
Current Medication ListPlease enumerate. Put N/A if not applicable.
13
Current Medication ListPlease enumerate.
14
Past Medical History* This field is required.Check all that apply
High blood pressure
High Cholesterol
Diabetes
Heart Problems
Lung Problems
Kidney Problems
Cancer
None
Others (please specify)
15
Others:Please specify
16
Have you ever had a surgery?* This field is required.
YESNO
17
If YES, please list surgeries you have had and the date of surgery if knownType of surgery and date.
Surgery
Date (MM-DD-YYYY)
Surgery
Date (MM-DD-YYYY)
Surgery
Date (MM-DD-YYYY)
Surgery
Date (MM-DD-YYYY)
18
Do you smoke?* This field is required.
YES - light
YES - heavy
YES - moderate
NO
19
Do you use recreational drugs?* This field is required.
YES - light
YES - heavy
YES - moderate
NO
20
Do you drink alcohol?* This field is required.
YES - light
YES - heavy
YES - moderate
NO
21
Family History of Medical Conditions?* This field is required.Check all that apply.
Stroke
High Blood Pressure
Dementia
Diabetes
Heart Disease
Other (please specify)
Cancer
None
22
Other:Please specify
23
Briefly describe what happened during the accident.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
24
Did police or paramedics come?* This field is required.
YESNO
25
Did you go to the hospital?* This field is required.
YESNO
26
What other doctors/treatments have you seen/done?Check all that apply
Chiropractor
Neurosurgeon
Physical Therapy
Injections (please specify)
Pain Management Physician
Surgeries (please specify)
Orthopedic Surgeon
Others (please specify)
27
If you have had injections, what body parts were injected:For example; neck or back
28
Others (please specify):Please specify
29
Have you had any MRI's done due to the accident?* This field is required.
YESNO
30
What body parts did you have imaged in the MRI?Check all that apply
Head
Neck
Low back
Other (please specify)
31
Other (please specify):Please specify
32
How much do you remember from the actual injury?* This field is required.Check all that apply
Completely
Not at all
Partially (bits and pieces)
33
Do you remember striking your head?
YESNO
34
If YES, where did you strike your headCheck all that apply
Steering Wheel
I don't know
Back of headrest
Others (please specify)
35
Other (please specify):Please specify
36
After the accident, when did you notice your symptoms or injuries?* This field is required.Check all that apply
Later that day
Within the next week
The next day
Other (please specifiy)
Immediately
37
Other (please specify):Please specify
38
Did you lose consciousness (pass-out)?* This field is required.
YESNO
39
Did airbags deploy?* This field is required.
YESNO
40
Did you forget or not remember parts of the accident, such as before, during, or after the accident?* This field is required.
YESNO
41
What symptoms did you immediately feel at the time of the accident?* This field is required.Check all that apply
Dazed
Felt like you were somewhere else
Confused
Shocked
Panicked
Fear
Adrenaline
Pain
Nausea
Others
Vomit
42
Other (please specify):Please specify
43
What body parts immediately had pain or other symptoms?* This field is required.Check all that apply
Head
Shoulder
Hip
Shocked
Elbow
Knee
Mid back
Wrist
Ankle
Vomit
Hand
Foot
Chest
Other (please specify)
Eyes
44
Other (please specify):Please specify
45
Check all the symptoms that developed or worsened after the injury.* This field is required.Check all that apply
Headache
Sound Sensitivity
Memory
Dizziness
Focus
Spinning Sensation
Attention
Lightheadedness
Concentration
Ringing/Noise in ears
Light Sensitivity
Irritability
Anxiety
Depression
Vision Change
Hearing Change
Loss of Smell
Behavioral Changes
Changes to Sleep
Others symptoms not on list
Other
46
Other symptoms not on the list (please specify):Please specify
47
Has it taken you longer to perform your work or home tasks?* This field is required.
YESNO
48
Do you have neck pain?* This field is required.
YESNO
49
If YES, does it radiate toCheck all that apply
Your Arms
Your Back
Your Head
Other (please specifiy)
50
Other (please specify):Please specify
51
Do you have low back pain?* This field is required.
YESNO
52
If YES, does it radiate to* This field is required.Check all that apply
Your buttocks
Does not radiate
Down your legs
Other (please specifiy)
53
Other (please specify):Please specify
54
Medical LienPlease review the document below. You will be asked to sign on the next page.
55
Please sign to acknowledge the Medical Lien.* This field is required.
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