General Intake Form

Dr. Olinka Hrebicek, Neurology

General Intake Form
Personal Information
Full Name*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Primary Care Provider*
Preferred pharmacy name and location*
Age*
Height*
Weight*
Handedness*
Describe your living situation (check all that apply):*

Live aloneLive with other(s)SpouseChildren at homeOther
Current Neurological Concerns
Neurological Concerns: Why are you here today?*
When did the problem start?*
Conditions/illnesses you have or have had (check all that apply). Add notes below if necessary:

ADHDAnxietyAutismBleeding TendencyBlood ClotsCancerDepressionDiabetesDrug Addiction*GlaucomaHead InjuriesHeart DiseaseHepatitisHigh Blood PressureHigh CholesterolHIVHypothyroidismIBD/Chrohn's DiseaseJaundiceKidney DiseaseLupusMigraine HeadachesPeptic Ulcer DiseasePneumoniaSleep ApneaSTI*StrokeTuberculosisOther
Notes about checked conditions/illnesses:
Medication Information
How many alcoholic drinks do you consume in a week?*
Have you quit previously?*

YesNo
Do you smoke?*
If you have quit smoking, when?
Recreational Drug Use:*
If you used in the past, when?
Previous Injuries
List all prescription medications (including dosage details) you currently take:
List any over-the counter drugs, supplements, herbs or vitamins you currently take:
List any significant diseases that run in your family (ie. diabetes, strokes, migraines, neurological diseases):
Review of Symptoms
Cardiovascular
Musculoskeletal
Skin
Gastrointestinal
Genitourinary
Neurologic
Eyes
Respiratory
ENT
Constitutional
Hematologic
PHQ-9 Nine Symptom Checklist
1) Little interest or pleasure in doing things

Not at allSeveral daysMore than half the daysNearly every day
2) Feeling down, depressed, or hopeless

Not at allSeveral daysMore than half the daysNearly every day
3) Trouble falling or staying asleep, or sleeping too much

Not at allSeveral daysMore than half the daysNearly every day
4) Feeling tired or having little energy

Not at allSeveral daysMore than half the daysNearly every day
5) Poor appetite or overeating

Not at allSeveral daysMore than half the daysNearly every day
6) Feeling bad about yourself - or that you are a failure or have let yourself or your family down

Not at allSeveral daysMore than half the daysNearly every day
7) Trouble concentrating on things, such as reading the newspaper or watching television

Not at allSeveral daysMore than half the daysNearly every day
8) Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual

Not at allSeveral daysMore than half the daysNearly every day
9) Thoughts that you would be better off dead or hurting yourself in some way

Not at allSeveral daysMore than half the daysNearly every day
If you checked off ANY problems, how DIFFICULT have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at allSomewhat difficultVery difficultExtremely difficult
GAD-7 Screening Questions
1) Feeling nervous, anxious, or on edge

Not at allSeveral daysMore than half the daysNearly every day
2) Not being able to stop or control worrying

Not at allSeveral daysMore than half the daysNearly every day
3) Worrying too much about different things

Not at allSeveral daysMore than half the daysNearly every day
4) Trouble relaxing

Not at allSeveral daysMore than half the daysNearly every day
5) Being so restless that it is hard to sit still

Not at allSeveral daysMore than half the daysNearly every day
6) Becoming easily annoyed or irritable

Not at allSeveral daysMore than half the daysNearly every day
7) Feeling afraid, as if something awful might happen

Not at allSeveral daysMore than half the daysNearly every day
If you checked off ANY problems, how DIFFICULT have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at allSomewhat difficultVery difficultExtremely difficult
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

Personal Information

Current Neurological Concerns

Medication Information

Review of Symptoms

PHQ-9 Nine Symptom Checklist

GAD-7 Screening Questions