Ravinder Arora, MD

RAVINDER ARORA,M.D.

PATIENT REGISTRATION

Account Number _________________________

PLEASE PRINT AND COMPLETE ALL BLANKS

PATIENT INFORMATION

NAME __________________________________ SS# _____________________

ADDRESS ___________________________________________________________

STREET CITY STATE ZIP

DATE OF BIRTH ___________ SEX _______________MARTIAL STATUS ____________

EMPLOYER: NAME ___________________________ ADDRESS __________________________

HOME PHONE __________________________ WORK PHONE ____________________________

SPOUSE OR NEXT OF KIN INFORMATION

NAME __________________________________ RELATIONSHIP _____________________

DOB ____________ SS# __________________

EMPLOYER: NAME _________________________ ADDRESS ____________________________

HOME PHONE ___________________________ WORK PHONE __________________________

EMERGENCY CONTACT

NAME ___________________________________ RELATIONSHIP ____________________

ADDRESS _________________________________________ PHONE __________________

INSURANCE INFORMATION

ACCIDENT RELATED 9Yes Date of Acc. _____________ 9No 9Auto 9Other ____________

EMPLOYMENT RELATED 9Yes Date of Acc. ___________ 9No 9Auto 9Other____________

MEDICARE: Identification Number _____________________________________

MEDICAID: Identification Number ______________________________________

OTHER INSURANCE: Primary ___________________________________

Secondary ________________________________

RELATIONSHIP TO INSURED: 9Self 9Child 9Spouse 9Other ______________________

REFERRED BY OR PRIMARY PHYSICIAN

NAME _________________________________________

ADDRESS _____________________________________ PHONE _____________________

LIFETIME CONSENT FORM

I authorize any holder of medical or other information about me to release to the _________________________ with whom I have health insurance coverage, any information for this or a related Medicare claim. I permit a copy of this authorization to be used in place of the original and I request payment of medical insurance benefits to include major medical to be made directly to Ravinder Arora, M.D. on any unpaid bills for services furnished to me by Ravinder Arora, M.D.

___________________________________________ _______________________________

Signature Date signed

RAVINDER ARORA, M.D.

2305 S. Highway 65

Marshall, MO 65340

HT: _______WT: ______ BP: _______ PR: _______ RE: __________ LE: ___________

Name _____________________________________________ Date ___________________

Age _____________ Sex: 9Male 9Female Right or Left Handed Occupation ______________________

Your reason for coming to Neurologist: (Please describe)

_____________________________________________________________________________________

Is the problem: 9Stable? 9Fluctuating? 9Getting Better? 9Getting Worse?

Additional problems of your nervous system:

_____________________________________________________________________________________

Previous tests for these problems: (Circle the one/ones done)

CT Scan Angiogram EEG EMG Spinal Tap Holter Monitor Myelogram EKG

X Ray Blood Tests MRI Sleep Studies Ultrasound

What medications are you on now? _________________________________________________________

______________________________________________________________________________________

Name the medications you have used in the past: ______________________________________________

______________________________________________________________________________________

ALLERGIES? __________________________________________________________________________

REVIEW OF SYSTEMS. Do you have, or ever had, any of the following? Check any that apply.

9Sinusitis 9Loss of Vision 9Glaucoma 9Chest Pain 9Palpitations 9Headache

9Shortness of Breath 9Swelling of Feet/Hands 9Varicose Veins 9Kidney Disease 9Diarrhea

9Constipation 9Loss of Appetite 9Fainting Spells 9Staggering 9Slurred Speech 9Tremor

9Double Vision 9Convulsions 9Depression 9Sleep Problem 9Paralysis of Bladder

9Hallucinations 9Paralysis of any part of the body 9Impairment of reading or writing

HAVE YOU BEEN DIAGNOSED WITH ANY OF THE FOLLOWING:

(Please check the appropriate answers.)

__Cancer __Diabetes __High Blood Pressure __Stroke __Epilepsy

__Joint Disease __Low Back Pain __VD __Neck Pain __Low Blood Pressure __Migraines __Meningitis __Thyroid Disease __Chest Disease __Multiple Sclerosis

__Parkinson’s Disease __Encephalitis

__Other Diseases__________________________________________________________________________________

________________________________________________________________________________________________

ANY SURGERIES OR HEAD INJURIES in the past? (Please give approximate dates and complications, if any.)

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

FAMILY HISTORY: Have any of your relatives had any of the following: Please mark F for father, M for mother, B for brother, S for sister, C for cousin, etc.

__Cancer __Diabetes __Heart Disease

__High Blood Pressure __Parkinson’s Disease

__Muscular Dystrophy __Psychiatric Illness

__Stroke __Epilepsy __Migraines

__Mental Retardation __Other _____________________

SOCIAL HISTORY: Do you use, or have you ever used, any of the below?

(Please give approximate duration and amounts.)

Alcoholic Beverages ____________________ Tobacco (chewing or smoking) ____________________

Marital Status: __Married __Single __Divorced __Widow/wer

Number and ages of children: __________________________________________________________________________

Any additional information that you would like to provide: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

NOTICE OF PRIVACY PRACTICES ACKNOWLEDEMENT

RAVINDER ARORA, M.D.

2305 S, Highway 65

Marshall, MO 65340

Clinic: 660-886-8414

Scheduling: 660-831-3208

Fax: 660-886-5091

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
Obtain payment from third-party payers.
Conduct normal healthcare operations such as quality assessments and physician certifications.

I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

Patient Name: _________________________________________________

Relationship to Patient: _________________________________________________

Signature: _________________________________________________

Date: _________________________________________________

_________________________________________________________________________________________________

OFFICE USE ONLY

I attempted to obtain the patient’s signature in acknowledgement on this Notice of Privacy Practices Acknowledgement, but was unable to do so as documented below:

Date: Initials: Reason: