Mark A. Spicer PhD MD
Andrew D. Nguyen MD PhD
Division of Neurosurgery
NEW PATIENT INTAKE FORM
I am a ______ year old
(right/left) handed (man/woman).
I was referred to Dr. Spicer/Nguyen by (myself/a friend/a relative
or Dr. ______________)—please circle one.
The following individuals have come with me to today’s office visit: (Please
list the individuals and their relationship to you)
_____________________________________________________________
_________________________________________________________
My closest contact is ___________________;
who can be reached at phone ______________________.
My cell phone is (don’t own one/___________________).
My email is (___________________________________).
As far as I know, I am being sent to see Dr. Spicer/Nguyen because I have
the following condition:
_____________________________________________________________
_________________________________________________________
or
____ I’m not sure.
DEPARTMENT OF SURGERY, DIVISION OF NEUROSURGERY
25150 Hancock Ave, Suite 210, MURRIETA, CALIFORNIA 92562 Telephone (951) 461-6988 Fax (951) 461-9080
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Mark A. Spicer PhD MD
Andrew D. Nguyen MD PhD
Division of Neurosurgery
I have had an (check all that apply):
□MRI scan
□CT scan
□Another type of test (specify): __________________
and it was ordered because I was experiencing:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
____________________________________________________.
I first began to notice these symptoms:
□_____day(s) ago
□_____week(s) ago
□_____year(s) ago
If your symptoms have become worse, please describe in what way:
_____________________________________________________________
_________________________________________________________
DEPARTMENT OF SURGERY, DIVISION OF NEUROSURGERY
25150 Hancock Ave, Suite 210, MURRIETA, CALIFORNIA 92562 Telephone (951) 461-6988 Fax (951) 461-9080
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Mark A. Spicer PhD MD
Andrew D. Nguyen MD PhD
Division of Neurosurgery
Other doctors who are part of my medical team (e.g. primary doctor or
cardiologist or oncologist) or neurologists or neurosurgeons who have
recently evaluated me are:
Dr.
Dr.
Dr.
Dr.
Dr.
Dr.
_______________
_______________
_______________
_______________
_______________
_______________
located
located
located
located
located
located
in
in
in
in
in
in
(town/state)
(town/state)
(town/state)
(town/state)
(town/state)
(town/state)
___________________
___________________
___________________
___________________
___________________
___________________
My medical history
I am taking the following medications:
Medication
Reason I am taking it
Dose that I take
DEPARTMENT OF SURGERY, DIVISION OF NEUROSURGERY
25150 Hancock Ave, Suite 210, MURRIETA, CALIFORNIA 92562 Telephone (951) 461-6988 Fax (951) 461-9080
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Mark A. Spicer PhD MD
Andrew D. Nguyen MD PhD
Division of Neurosurgery
Other medical problems (diabetes, heart attacks, hepatitis, etc) that I have
been treated for now or in the past include:
_____________________________________________________________
_____________________________________________________________
_______________________________________________________
Check one:
□I have NO medication allergies
□I am ALLERGIC to the following medications: (list reaction to medication)
_____________________________________________________________
_____________________________________________________________
_______________________________________________________
I have had surgeries in the past, they include the following:
(List all prior surgeries and estimate of year of the surgery).
SURGERY:
_________________________
_________________________
YEAR:
______________________
______________________
_________________________
_________________________
_________________________
_________________________
______________________
______________________
______________________
______________________
DEPARTMENT OF SURGERY, DIVISION OF NEUROSURGERY
25150 Hancock Ave, Suite 210, MURRIETA, CALIFORNIA 92562 Telephone (951) 461-6988 Fax (951) 461-9080
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Mark A. Spicer PhD MD
Andrew D. Nguyen MD PhD
Division of Neurosurgery
My history of smoking is as follows:
□I have never smoked.
□I currently smoke about ____ (cigarettes/packs) (circle one)
per day. How long? _________
□I used to smoke about ______ packs per day but I stopped ______
(weeks/months/years) ago (circle one).
History of alcohol use:
□I have never used alcohol.
□I used to drink alcohol but stopped ___ years ago.
□I drink alcohol…..about ________ drinks per (day/week) (circle one).
Some of the medical conditions that run in my family include:
My father has had _________________________
My mother has had_________________________
Other relatives have experienced__________________
I am approximately _____ feet______ inches tall;
I weigh about ___________ pounds.
DEPARTMENT OF SURGERY, DIVISION OF NEUROSURGERY
25150 Hancock Ave, Suite 210, MURRIETA, CALIFORNIA 92562 Telephone (951) 461-6988 Fax (951) 461-9080
Page 5 of 7
Mark A. Spicer PhD MD
Andrew D. Nguyen MD PhD
Division of Neurosurgery
Check all that apply:
□ My speech is clear & understandable OR
□ I have trouble expressing myself.
□ My vision is good
OR
□ I have been having vision trouble in my (right/left/both eyes) (circle one).
□ I have good strength in my arms and legs OR
□ my (right/left) (circle one) arm and my (right/left) (circle one) leg is weak.
□ I can walk on my own OR
□ I use a cane OR
□ I use a walker OR
□ I use a wheelchair
□ I live at home alone OR
□ I live with others (list whom you live with):
_____________________________________________________
I am currently:
□ retired
□ employed (circle one)(full-time/part-time) at: ______________ .
DEPARTMENT OF SURGERY, DIVISION OF NEUROSURGERY
25150 Hancock Ave, Suite 210, MURRIETA, CALIFORNIA 92562 Telephone (951) 461-6988 Fax (951) 461-9080
Page 6 of 7
Mark A. Spicer PhD MD
Andrew D. Nguyen MD PhD
Division of Neurosurgery
One other bit of information that I would like to pass along is:
_________________________________________________________
_________________________________________________________
_________________________________________________________
Authorization to Discuss Medical Condition
I give permission to the physicians and office staff of UCSD Neurosurgery & Surgical Specialties to discuss my medical conditions
with the following family members/friends:
NAME:
____________________________
Relationship: _____________________________________
NAME:
____________________________
Relationship: _____________________________________
NAME:
____________________________
Relationship: _____________________________________
__________________________________________________
PRINT NAME
__________________________________________________
_________________________
SIGNATURE
DATE
__________________________________________________
RELATIONSHIP TO PATIENT IF MINOR
DEPARTMENT OF SURGERY, DIVISION OF NEUROSURGERY
25150 Hancock Ave, Suite 210, MURRIETA, CALIFORNIA 92562 Telephone (951) 461-6988 Fax (951) 461-9080
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