General Follow-Up Form - Appointment Date:
Dr. Olinka Hrebicek, Neurology
General Follow-Up Form
Personal Information
Full Name
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Daytime phone number to reach you:
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Email
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example@example.com
Primary Care Provider
*
Preferred Pharmacy (Name & Location):
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Age
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Height
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Weight
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Neurological Concerns: Why are you here today?
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When did the problem start?
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Have you had any new diagnoses since your last visit?
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No
Yes
Has there been a change in your medications since your last visit?
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No
Yes (List new medications and/or dosages below)
List your new medications and/or dosages (if applicable):
Do you have any medication allergies?
*
Yes (please list below)
No
Medication allergies:
Do you have extended benefit coverage?
No
Yes
Since your last visit, have you experienced problems with:
Balance
Bathing
Bladder
Bowel
Climbing/descending stairs
Coordination
Dressing
Fatigue
Feeding
Grooming
Hearing
Memory (short/long term)
Mobility
Mood and thought disturbances
Muscle spasticity/stiffness
Pain
Sexual function
Speech
Transfers
Vision
Relapse (appearance of new or worsening of old symptoms lasting at least 24 hours)
Other
For those on injectable drugs:
Missed injection
Problems at injection site
Side-effects
Other
Is there any additional information you would like to share with Dr. Hrebicek?
Interactions between Dr. Hrebicek, office staff and patients should always be professional, respectful and courteous. If I am unable to meet this expectation, I understand that it may affect my ability to continue as a patient in this practice.
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I understand
I understand that there may be a fee for certain services performed by the doctor. (Ie. Completing insurance forms or other tasks, according to the Doctors of BC Fees for Uninsured Services.)
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I understand
Submit
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