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Rafael Yakutilov Neurology PC

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Rafael Yakutilov Neurology PC Intake

Date picker

First name*

Last name*

Sex

Male

Female

Birthday*

Month

Day

Year

Social Security #

Marital Status

Home Phone*

Cell Phone

Email

Multi-line address

Country/Region*

Address*

Address - line 2*

City*

Zip / Postal code*

Employer Name

Occupation

Business Phone

Emergency Contact

Emergency Contact Phone

Copy of Insurance Card

Insurance Company*

Insurance Policy #*

Policy Holder's Name

Insured's Date of Birth

Sex of Policy Holder

Male

Female

Relationship*

Self

Sponse

Parent

Other

I authorize assignment of insurance benefits and release of medical information for billing and treatment

I acknowledge receipt and understanding of the Notice of Privacy Practices (HIPAA)

I certify that I (or my dependant) have insurance coverage and assign Rafael Yakutilov MD all insurance benefits, if any, otherwise payable to me for services rendered. I financially responsible for all charges whether or not paid by insurance.

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Chief Complaint & Neurologic Symptoms

Provider information

Primary Care Physician

Referring Physician

Dominant Hand

Left

Right

Both

Medications

Allergies

Past Medical History

Hypertension

Diabetes

Stroke / TIA

Seizures / Epilepsy

Multiple sclerosis

Parkinson’s disease

Alzheimer’s disease

Head injury

Brain tumor

Heart disease

Pacemaker

Asthma / COPD

Sleep apnea

Kidney disease

Liver disease

Thyroid disease

Cancer

Depression

Anxiety

Fibromyalgia

Chronic pain

Other

Reason For Visit

Review of Systems (Past Year)

General: Fever, chills, night sweats, weight change, fatigue

Psychiatric: Anxiety, depression, panic attacks, hallucinations

HEENT:Hearing loss, ringing in ears, swallowing difficulty, vision loss

Cardiovascular:Chest pain, palpitations, irregular heartbeat, fainting

Respiratory:Shortness of breath, wheezing, cough

Gastrointestinal:Nausea, abdominal pain, constipation, diarrhea, rectal bleeding

Genitourinary:Urinary frequency, blood in urine, incontinence

Musculoskeletal:Neck pain, back pain, joint pain, arthritis

Endocrine:Diabetes, thyroid disease

Hematologic:Anemia, easy bruising

Skin:Rashes, skin changes

What is the main reason for today’s visit?

Neurological Symptoms

Weakness in limbs

Speech problems

Tingling or numbness in hands or feet

Weakness on one side of body

Sensory loss on one side of body

Visual loss in one eye

Seizures or convulsions

Febrile seizures in childhood

Loss of consciousness

Loss of balance

Dizziness / lightheadedness / spinning

Fainting spells or syncope

Memory loss

Getting lost or wandering

Swallowing problems

Tremor

Muscle cramps

Involuntary movements

Tics

Chronic fatigue

Widespread aches and pains

Light sensitivity

Nausea with headaches

Flashing lights before headaches

Urinary incontinence

Seizure Details

Have you ever had seizures?

Yes

No

If yes

Age of 1st seizure? Frequency?

Loss of consciousness?

Yes

No

Aura?

Yes

No

Headaches & Pain

Headaches

How long have you had headaches? How Often?Rate severity (Linear scale 1–10)

Pain

Rate severity (Linear scale 1–10). Location of pain ? Frequency?

Family History

Mother Living ? Mother's health conditions?

Father Living ? Father's health conditions?

Social History

Do you smoke?*

Yes

No

Do you drink alcohol?*

Yes

No

Do you use recreational drugs?*

Yes

No

I unsigned herby aurthorize Dr. Rafael Yakutilov to render treatment to myself that he deems medically necessary in order to treat the condition or the conditions and have a opportunity to read HIPPA notice if requested.*

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p.718.474.0023

f. 347.708.9696

ryneurology@gmail.com

Rockaway Park Location:

15 Beach 105th Street

Rockaway Park, NY 11694

Rego Park Location:

62-58 Ellwell Crescent

Rego Park , NY 11374

Rafael Yakutilov Neurology PC

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