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
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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?
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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
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
Should be Empty: