General Follow-Up Form

Dr. Olinka Hrebicek, Neurology

General Follow-Up Form
Personal Information
Full Name*
Email*
example@example.com
Primary Care Provider*
Preferred Pharmacy (Name & Location):*
Age*
Height*
Weight*
Neurological Concerns: Why are you here today?*
When did the problem start?*
Have you had any new diagnoses since your last visit?*

NoYes
Has there been a change in your medications since your last visit?*

NoYes (List new medications and/or dosages below)
List your new medications and/or dosages (if applicable):
Since your last visit, have you experienced problems with:

BalanceBathingBladderBowelClimbing/descending stairsCoordinationDressingFatigueFeedingGroomingHearingMemory (short/long term)MobilityMood and thought disturbancesMuscle spasticity/stiffnessPainSexual functionSpeechTransfersVisionRelapse (appearance of new or worsening of old symptoms lasting at least 24 hours)Other
For those on injectable drugs:

Missed injectionProblems at injection siteSide-effectsOther
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.*

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.)*

I understand
Should be Empty:

Dr. Olinka Hrebicek, Neurology