Neurology Headache and Pain Clinic Sachin R. Shenoy, M.D. Board Certified in Neurology and Pain Management
Social security # _______________________
Cell Phone ____________________________ Best Phone # to call (please circle) Home Cell
Referred By (Please List): Physician _________________________ Friend_________ Family _______________
Heard about us from _____ Newspaper ____ Yellow Pages _______Radio _____ Internet ________
Mailing address _________________________________________________
Have you ever seen Dr. Shenoy prior to today for any medical reason? Yes / No
Employer __________________________________
Local person to contact in case of emergency ___________________ Phone # _______________________________
Primary Insurance _________________________
Card Holders Name ________________________________
Secondary Insurance ___________________________ Card Holders Name ________________________________
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA) (ALL PATIENTS MUST
I acknowledge that I have been given the opportunity to read the Heath Insurance Portability and Accountability Act of 1996 (HIPAA), and I agree to the terms set forth. Please Note: If your copy is missing there is a copy on the wall to the left of the check in window. X__________________________________________________________________________________________________
AUTHORIZATION FOR US TO BILL MEDICARE FOR YOUR VISITS
I authorize payment of Medicare benefits to Sachin R. Shenoy MD, PA I authorize the release/transmission of pertinent medical
information necessary to determine benefits. I realize that I am responsible for deductibles, co-payments, and non-covered
X _____________________________________________________________________________________________________
AUTHORIZATION FOR US TO BILL YOUR COMMERCIAL OR SECONDARY INSURANCE FOR YOUR VISITS
I authorize payment of insurance benefits directly to Sachin R. Shenoy MD, PA and the release/transmission of pertinent
medical information necessary to determine benefits. I am responsible for all charges not covered by insurance contracts,
including co-payments, deductibles, non-covered services, and those determined by the insurance company to be above their
X _________________________________________________________________________________________________
1845 Jess Parrish Ct. Titusville, FL 32796 Phone (321) 264-2011 Fax (321) 264-0442 Page | 1 Neurology Headache and Pain Clinic Sachin R. Shenoy, M.D. Board Certified in Neurology and Pain Management
Patient name___________________________________________
PLEASE DESCRIBE YOUR PROBLEM IN A FEW WORDS:
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PAST MEDICAL HISTORY
If yes, please name type of Cancer _________________________________________
Please List_____________________________
PAST SURGICAL HISTORY
NO PRIOR SURGERIES ____ (Please proceed to next paragraph) Tonsillectomy
If yes, date(s)__________Type of surgery done _________________________
If yes, date(s)__________ Type of surgery done _________________________
If yes, date(s)__________ Type of surgery done _________________________
Please list any additional surgeries and date__________________________________________________________________ PERSONAL HISTORY
Marital Status: Single _____ Married _____ Divorced _____ Widowed
If In the past when did you stop, what and how much did you consume ____________________
If In the past when did you stop, what and how much did you consume ____________________
If In the past when did you stop, what and how much did you consume ____________________
1845 Jess Parrish Ct. Titusville, FL 32796 Phone (321) 264-2011 Fax (321) 264-0442 Page | 2 Neurology Headache and Pain Clinic Sachin R. Shenoy, M.D. Board Certified in Neurology and Pain Management
FAMILY HISTORY
Major Illnesses _____________________________________
Major Illnesses _____________________________________
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Medications and dosage: (Please list all medications, dosages, and indicate how often you take the medication.) 1) _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Please List any allergies that you have
1.____________________________________________________________ 2.____________________________________________________________ 3.____________________________________________________________ 4.____________________________________________________________ 1845 Jess Parrish Ct. Titusville, FL 32796 Phone (321) 264-2011 Fax (321) 264-0442 Page | 3 Neurology Headache and Pain Clinic Sachin R. Shenoy, M.D. Board Certified in Neurology and Pain Management
Please indicate any if you have had any of the symptoms mentioned below in the last Stomach related three months by circling the yes response. If you have not had Nervous system symptoms the symptom listed below please do not circle. General Symptoms Urination and Sexual symptoms Psychiatric Ears/Nose/Mouth/Throat Muscle and joint related Hormone related Heart related Skin and Breast Blood related Lung related To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor’s office of any changes in my medical status. I authorize the healthcare staff to perform the necessary services I may need. I authorize Dr Shenoy and his staff to release to a physician/s of my choosing and to discuss my care with him/ her / them as needed. I also give Dr Shenoy permission to discuss my health issues with my prior treating physicians if needed. . I also authorize Dr Shenoy and or members of his staff to discuss my information as required by law with any law enforcement agency or other enforcement agencies if required by law.
__________________________________________________________________________________________________ ______________________________________________________ Signature of Patient or Parent or Legal Guardian 1845 Jess Parrish Ct. Titusville, FL 32796 Phone (321) 264-2011 Fax (321) 264-0442 Page | 4
Neurology, Headache, and Pain Management Clinic
1845 Jess Parrish Ct, Titusvil e, Fl 32796
Authorization To Release Medical Records I, ______________________________________________, do hereby consent and authorize Dr. Sachin Shenoy to disclose to _____________________________________________ information from my medical records relating to identity, diagnosis, prognosis, or treatment, including psychiatric disorders and substance abuse, results of HIV testing, diagnosis of Acquired Immune Deficiency Syndrome and diagnoses related to AIDS. I understand that the specific type of information to be released includes: medical records, x-ray reports, laboratory reports, admissions, consults, operative notes, and discharge summaries, and that the purpose or need for this disclosure is to continue medical care and/or provide information to the other parties as named above at my request. ________________________________ ____________________________
Signature of patient, legal guardian, or
_______________________________ ____________________________ Phone _____ - _____ - _______ Fax _____ - _____ - _______ Attention ________________________
Neurology, Headache, and Pain Management Clinic
1845 Jess Parrish Ct, Titusvil e, Fl 32796
Patient Request and Authorization To Release Medical Records I, ______________________________________________, do hereby consent and authorize _________________________________________ to disclose to Dr. Sachin Shenoy information from my medical records relating to identity, diagnosis, prognosis, or treatment, including psychiatric disorders and substance abuse, results of HIV testing, diagnosis of Acquired Immune Deficiency Syndrome and diagnoses related to AIDS. I understand that the specific type of information to be released includes: medical records, x-ray reports, laboratory reports, admissions, consults, operative notes, and discharge summaries, and that the purpose or need for this disclosure is to continue medical care and/or provide information to the other parties as named above at my request. ________________________________ ____________________________
Signature of patient, legal guardian, or
_______________________________ ____________________________ Phone _____ - _____ - _______ Fax _____ - _____ - _______ Attention ________________________
Board Certified in Adult Neurology and Pain Management
Patient Name: ___________________________________________ Date:_____________________
If you have been on or tried any of the medications below, please circle. If a medication has worked for you in the past please indicate so it can possibly be tried again. Please also list side effects next to the medication if any are known.
Anti-Depressants Sedative- Hypnotics SSRI’s
Chlordiazepoxide hydrochloride (Librium)
SNRI’s MAO Inhibitors NSAID’s Narcotic Analgesics Non-Narcotic Analgesics Beta-Blockers
Hydrocodone (Lortab,Lorcet) Carvedilol (Coreg)
Migraine Medications Muscle Relaxants Epileptic Medications Multiple Sclerosis
1845 Jess Parrish Ct, Titusvil e, FL 32796 (P) 321-264-2011 (F) 321-264-0442
Residential Property Inspections Ph:(707) 310-0206 www.pacificinspections.net Property Condition Report for: 555 Anywhere Avenue, Santa Rosa CA ELECTRICAL SYSTEM Electrical features are operated with normal controls. The general wiring, switches, outlets and fixtures arerandomly checked in accessible areas. Wiring in the electrical panels is inspected by removing the cover i