Follow-up Visit Patient Questionnaire

Name

Today's Date

Current Insurance

ID #

Signature

Secondary Insurance

ID #

Signature

Purpose of today’s visit

IF YOU SUFFER FROM SEIZURE, CONVULSIVE DISORDER, EPILEPSY, FAINTING OR DIZZY SPELLS, OR ANY CONDITION WHICH CAUSES UNCONCIOUSNESS NYS LAW REQUIRES THAT YOU DO NOT DRIVE FOR 1 YEAR AFTER THE LAST EVENT.

Please LIST YOUR CURRENT MEDICATIONS (please indicate in the notes any new medications since your last visit here)

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Did you change the dose of any medication? If so, why?

Family history

Social History

Smoking

Y N

Alcohol

Y N

Drug Use

Y N

Do you have any allergies?

Since your last visit, has there been any change in your general medical status?

Since your last visit, have you undergone any surgery/procedure?

Are you experiencing any of the following:

Fever

Y N

Cough

Y N

Skin problem

Y N

Sleepiness/sedation

Y N

Visual changes

Y N

Constipation/Diarrhea

Y N

Bleeding or Bruising

Y N

Difficulty sleeping

Y N

Hearing loss

Y N

Hot flushes or Impotence

Y N

Headcaches

Y N

Anxiety

Y N

Heart Disease

Y N

Bone/Joint pain

Y N

Change in mental acuity/memory

Y N

Depression

Y N

Please use the space to elaborate when pertinent.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature

Patient unable to provide ROS/medication list due to impaired mental status from current or chronic illness and sedation/intubation

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All other systems are negative

CONSENT TO RECEIVE THE APPOINTMENT REMINDERS THROUGH MOBILE PHONE TEXT MESSAGING

Last Name

Middle Name

First Name

Birth Date

Mobile Phone Number

Patient Signature

Date

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