Neurology Specialists of the Treasure Coast, P.A. Daniela Saadia, M.D. 900 SE Ocean Blvd. Suite 220 C Stuart, FL 34994 Phone 772-888-2611 Fax 855-667-1903

First Name_________________________________ Middle _______ Last Name _____________________________________

Date of Birth_______________________________ Gender: Male Female

Address________________________________________ City_______________________ State ______ Zip________ EMAIL ADDRESS: (Print clearly) _____________________________________________________________________________

Primary Phone Number: _________________________________________ Home Cell Secondary Phone Number: _________________________________________ Home Cell Marital Status: Married Single Separated Divorced Widowed

Emergency Contact: ________________________________________________

Relationship to Patient: ______________________________ Phone Number:____________________________________

Primary Insurance:___________________________________ Secondary Insurance: _______________________________

CONSENT FOR E-PRESCRIBING & MEDICATION HISTORY

I understand that as a part of my electronic health record, Neurology Specialists of the Treasure Coast will transmit my prescriptions electronically as permitted, to the pharmacy that I designate as my primary pharmacy provider. Additionally, Neurology Specialists of the Treasure Coast will obtain the history of all of my past prescriptions dating back two years from pharmacy benefit managers and I understand that those prescriptions will become a part of my electronic health record. By signing below I hereby give consent to the above actions.

Signature of Patient or Legal Representative: _____________________________________Date: ________________

CONSENT TO TREAT, RECORD RELEASE & ASSIGNMENT OF INSURANCE

I voluntarily consent to any and all health care treatment and diagnostic procedures provided by Neurology Specialists of the Treasure Coast, P.A. I hereby authorize Neurology Specialists of the Treasure Coast., to re-release any and all medical information that has been previously requested from any physician, hospital, or clinic where I have been treated. I understand this authorization to re-release medical information shall only be valid for the purposes of second opinions or referral from Neurology Specialists of the Treasure Coast, P.A. I acknowledge full responsibility for the payment of services rendered to me and agree to pay for them in full, at the time of service, unless other arrangements are made in advance. I understand I am financially responsible for all non-covered services, copays, deductibles and/or coinsurance. I understand that I am financially responsible for any charges incurred in the collection of this account, should I default on payment. Such charges include, but are not limited to legal fees, collections fees, interest charges or late charges. I authorize the physician to release any medical information required to process my claims. I hereby assign my insurance benefits to be paid directly to the physician.

Signature of Patient or Legal Representative: _____________________________________Date: ________________

Neurology Specialists of the Treasure Coast, P.A. Daniela Saadia, M.D.

900 SE Ocean Blvd., Suite 220C Stuart, FL 34994 Phone (772) 772-888-2611 Fax (855) 667-1903

PRIVACY PRACTICES AND HIPAA RELEASE

I authorize this practice to discuss my medical care, test results and financial information with the family members or friends listed below, who are involved in my medical care. Furthermore, I authorize voicemail messages and text messages, if applicable, to be left for me at the phone numbers I have provided to this practice.

Name Phone Number Relationship

CANCELLATION AND NO SHOW POLICIES

Neurology Specialists of the Treasure Coast, P.A. requires a cancellation notice at least 24 hours in advance when I am unable to keep an appointment.

If I do not provide a proper cancellation notice or NO SHOW for an appointment, I am aware there is a $50 fee per occurrence.

I am aware if I incur this fee, it must be paid in full, by cash or check, prior to being seen at my next appointment.

Multiple cancellations or missed appointments in any 12 month period will result in dismissal from the practice.

By signing below, I acknowledge I have read this notice and understand the cancellation and no show policies for Neurology Specialists of the Treasure Coast, P.A. I acknowledge that I have received, or am aware of how I can obtain, a copy of the Neurology Specialists of the Treasure Coast. P.A. “Notice of Privacy Practices” which sets forth their privacy practices and my rights regarding privacy of my PHI (Protected Health Information). ____________________________________________ Patient Name ____________________________________________ ___________________________ Patient Signature (or Legal Representative) Date

Neurology Specialists of the Treasure Coast, P.A. Daniela Saadia, M.D. (772) 888-2611

Medical History

Patient______________________________________________dob______________Date_______________

Please briefly describe the symptom(s) or diagnosis that brought you to our office: _______________________________________________________________________________________

How long have you had these symptom(s) or diagnosis:___________________________________________

PATIENT HISTORY: (Please check all that apply)

Alzheimer’s Disease ___ Dementia ___ Mental Illness ___ Anxiety ___ Depression ___ Migraines ___ Atrial Fibrillation ___ Diabetes ___ Multiple Sclerosis ___ Back Problems ___ Epilepsy ___ Neck Problems ___ Bladder/Kidney Disease ___ Fainting ___ Parkinson’s Disease ___ Bleeding Disorder ___ Headaches ___ Seizure Disorder ___ Blood Thinners ___ Head Injury ___ Sleep Apnea ___

Brain Aneurysm ___ Heart Disease ___ Stroke ___

Brain Tumor ___ High Blood Pressure ___ TIA ___

Cancer ___ Lung Disease ___ Tremor ___

Other _________________________________________________________________________________

FAMILY HISTORY: (Please check all that apply)

Relationship Relationship

Alzheimer’s Disease ___ __________________ Heart Disease ___ __________________

Brain Aneurysm ___ __________________ Mental Illness ___ __________________

Brain Tumor ___ __________________ Muscle/Nerve Disorder ___ __________________

Cancer ___ __________________ Parkinson’s Disease ___ __________________

Dementia ___ __________________ Seizure Disorder ___ __________________

Depression ___ __________________ Stroke / TIA ___ __________________

Diabetes ___ __________________ Tremor ___ __________________

Other _________________________________________________________________________________

PAST SURGICAL HISTORY: (Please list previous surgeries and approximate dates)

-1-

Patient_______________________________________________________dob______________Date______________

SOCIAL HISTORY: (Please check appropriate response)

Do you live alone Yes No

Do you drive Yes No

Handedness Right Left Both

Have you previously used Tobacco Yes No

Do you currently use Tobacco Yes No

If yes to either of the above

How many per day ______________________

How many years ______________________

When did you quit ______________________

What types(s) Cigarettes Pipe Cigar Chewing Tobacco

Do you drink Alcohol Yes No

If yes, how often _____________________________

How much _____________________________

What type(s) Beer Wine Liquor

Do you drink Caffeine Yes No

If yes, how often ______________________________

How much ______________________________

What type(s) Coffee Soda Tea

Illicit Drug Use Yes No

If yes, how often _______________________________

What type(s) _______________________________

For Women: Are you pregnant Yes No

Are you breastfeeding Yes No

-2-

Neurology Specialists of the Treasure Coast, P.A. Daniela Saadia, M.D.

(772) 888-2611 Fax (855) 667-1903

Patient_______________________________________________dob______________Date______________

Please neatly list all CURRENT MEDICATIONS you are taking. Please also include over the counter

medications, herbal supplements and vitamins. You may also attach a list to the chart.

Do you have any ALLERGIES to medications? Yes___ No___ (If yes, please list)

-3-

MEDICATION STRENGTH FREQUENCY PRESCRIBER

Patient Name _______________________________________________dob_______________Date_______________

Please check all symptoms you are currently experiencing or have experienced in the past 2 weeks.

Constitutional Fever ___ Night sweats ___ Weight gain ___ Weight loss ___ Eyes Vision change ___ Dry eyes ___ Eye irritation ___ Double vision ___ Ears Difficulty hearing ___ Ringing in ears ___ Nose/Mouth Nosebleeds ___ Sinus problems ___ Sore throat ___ Bleeding gums ___ Snoring ___ Dry mouth ___ Swallowing Issues ___ Cardiovascular Chest pain ___ Shortness of breath ___ Palpitations ___ Chest pain on exertion ___ Arm pain on exertion ___ Heart murmur ___ Lightheadedness upon standing ___

Respiratory Cough ___ Wheezing ___ Sleep apnea ___ Gastrointestinal Abdominal pain ___ Vomiting ___ Bowel incontinence ___ Change in appetite ___ Black or tarry stools ___ Frequent diarrhea ___ Indigestion ___ GERD ___ Blood in stool ___ Nausea ___ Genitourinary Bladder incontinence ___ Blood in urine ___ Difficulty urinating ___ Urinary frequency ___ Incomplete emptying ___ Musculoskeletal Muscle aches ___ Joint pain ___ Back pain ___ Swelling in legs/arms ___ Muscle weakness ___ Integumentary Skin rash ___ Abnormal mole ___ Itching ___ Dry skin ___

-4-

Neurologic Loss of consciousness ___ Weakness ___ Numbness ___ Seizures ___ Dizziness ___ Migraines ___ Headaches ___ Tremor ___ Difficulty walking ___ Restless legs ___ Memory loss ___ Sleep disturbance ___ Daytime sleepiness ___ Psychiatric Depression ___ Alcohol abuse ___ Anxiety ___ Hallucinations ___ Feeling unsafe ___ Suicidal thoughts ___ Endocrine Fatigue ___ Increased thirst ___ Hair loss ___ Cold intolerance ___ Hematologic/Lymphatic Swollen glands ___ Easy bruising ___ Excessive bleeding ___ Allergic/Immunologic Runny nose ___ Sinus pressure ___

Reviewed by: _____________