Multiple Sclerosis Center of Nebraska

~  1  ~  

Multiple Sclerosis Center of Nebraska

Initial Visit Patient Information (Multiple Sclerosis) To be Completed Before Appointment

Date: ___________

Patient Name: _________________________________ DOB:___________________

Address:________________________________________________________________________

Social Security Number: ___________________________________________________________

Power of Attorney (if applicable): ____________________________________________________

Do you have an Advance Directive?: _________________________________________________

Who referred you to our office?:_____________________________________________________

Primary Care Physician (PCP) or Nurse Practitioner:____________________________________

PCP Address (City, State):__________________________________________________________

Pharmacy:__________________________________/_____________________________________

Name Address (City, State) Home Phone:___________________________________Daytime Phone:_______________

Cell Phone:________________________Email:____________________________________ Are you employed? ___ Yes ___ No

If Yes, Employer:_____________________________Occupation:_______________________

Are you disabled?: ______________________________

Reason for Clinic Visit:

________________________________________________________________________ ________________________________________________________________________

Reason for Clinic Visit: (please check one)

____ I have been diagnosed with MS and seek continued care

Diagnosis Date:______ By Whom was Diagnosis Made?__________ ____ I have not been diagnosed with MS, but may have it

____ I seek a second opinion about diagnosis/therapy

~  2  ~  

Multiple Sclerosis Center of Nebraska Intake Form (continued) Date of FIRST symptom(s): ______________________________________________

What symptom(s) did you experience at that time? _____________________________ Duration of symptoms:_____________ (hours/days/weeks/months/years).

Did you receive treatment for the symptoms?__________________________________ If so, what type of treatment did you receive?_______________________________

New symptom events (or attacks of MS) (Please list in chronological order starting with the most recent: Month/Year Symptom Events Began Symptom(s) Duration of Symptoms Was/Were Symptom(s) Treated With Steroids? Did Symptom(s) Resolve Completely?

Please read through the following list carefully and circle any medications you have ever taken. Avonex (interferon beta-1a) Betaseron (interferon beta-1b) Gilenya (fingolimod) Rebif (interferon beta-1a) Copaxone (glatiramer acetate) Azasan (azathioprine) Tysabri (natalizumab) Cytoxan (cyclophosphamide) Neosar (cyclophosphamide) Rituxan (rituximab) Extavia (interferon beta-1a) Neoral (cCyclosporine) Cellcept (mycophenolate mofetil) Sandimmune (cyclosporine) Arava (leflunomide)

Imuran (azathioprine) Leustatin (cladribine) Purinethol (mercaptopurine) Solumedrol (methylprednisolone) Decadron (dexamethasone) Methotrex (methotrexate) Prednisone Plasma exchange/pheresis Rheumatrex (methotrexate) Intravenous Immunoglobulin (IVIG) Novantrone (mitoxantrone) Trexall (methotrexate) Fludara (fludarabine phosphate) Alimta (premetrexed) Actimmune (interferon) Infergen (interferon) Intron A (interferon) Pegasysy (interferon) PEG-Intron (interferon) Rebetron (interferon) Roferon-A (Interferon) Humira (adalimumab) Amevive (alefacept) Campath (Alemtuzumab) Kineret (anakinra) Zenapax (daclizumab) Raptiva (Efalizumab) Enbrel (etanercept) Remicade (infliximab) Herceptin (trastuzumab) Aubagio (teriflunomide) Tecfidera (dimethyl fumarate) Ampyra (aminopyridine) Please provide details for any of the above medications you have taken:

Medication Name Dates on Treatment Start-End Date(s)

~  3  ~  

Multiple Sclerosis Center of Nebraska Intake Form (continued) Please list any other medications you have taken for MS symptoms:

Medication Name Dates on Treatment Start-End Date(s)

Reason for Stopping

Please provide details for your current medications (including vitamins and/or natural supplements): Medication/Supplement Name Dose and How Often Reason for Taking this Medication

Medication Allergies (Please include contrast dye (CT or MRI) if applicable): ___I have no known drug allergies

Medication: Reaction: __________________________ _______________________________ __________________________ _______________________________ __________________________ _______________________________

Please list Diagnostic Tests You Have Had.

Diagnostic Test Type: Where Done? Date of Most Recent Study

Brain MRI Spine MRI Spinal Tap

Visual Evoked Potentials Nerve Conduction Study

~  4  ~  

Multiple Sclerosis Center of Nebraska Intake Form (continued) Past Surgeries:

Type: Year: Type: Year:

___________________ ___________ ___________________ ___________

___________________ ___________ ___________________ ___________ ___________________ ___________ ___________________ ___________

Medical History: Have you ever had or been diagnosed with any of the following:

Stroke/TIA Irregular Heart Rate Pneumonia

Epilepsy Valve Problems: (e.g.,

Prolapse, Murmers)

Bronchitis

Seizures High Cholesterol Thyroid Problems

Parkinson's Disease Fainting Ear, Nose or Throat Problems

Tremor Anemia Eye Problems

Migraine Easy Bruising Skin Problems

Meningitis Blood Clotting Problems HIV/AIDS

Concussion Transfusion Mononucleosis

Dizziness Hepatitis Gout

Kidney Stones Liver Disease Miscarriage

Dialysis Stomach Ulcers or Bleeding Sjorgens

Chronic Kidney/Bladder/ Urinary Tract Infections

Gallbladder Problems Lupus

Kidney Failure GERD Crohn's Disease

Diabetes Irritable Bowel Syndrome Rheumatoid Arthritis

Prostrate Problems Diarrhea Sarcoidosis

Heart attack Asthma Psychological Problems

Chest Pain Emphysema/COPD Depression

Hypertension Tuberculosis Anxiety

Cancer: __________________________________________ Other:_______________________________________________

How would you describe your race:

___White, Non-Hispanic ___African American ___Native American

___White, Hispanic ___Asian ___Other:________________ Marital Status: ___Single ___Married ___Divorced ___Widowed

Number of Years of Education: _________

~  5  ~  

Multiple Sclerosis Center of Nebraska Intake Form (continued) Family History:

Alive Age or Age of Death Major Diseases

Mother ___Yes ____No _________________ _______________________________

Father ___Yes ____No _________________ _______________________________

Siblings ___Yes ____No _________________ _______________________________

___Yes ____No _________________ _______________________________

Nicotine Product use:

___Never ___Former

Stopped (Number of years ago):________

Amount Used: _____ Packs of cigarettes/ Cans / Cigars per day for ______years ___Current

Amount Used: _____ Packs of cigarettes/ Cans / Cigars per day for ______years

Alcohol use:

___Never ___Yes

Number of drinks: ___per day / ____per week / ____per month

Recreational drug use:

___Never

___Only in the past,

Stopped (Number of years ago):________

Types of Drugs Used:________________Any history of IV Drug Use: ___No ___Yes ___Current

Types of Drugs Used:________________Any history of IV Drug Use: ___No ___Yes

Exercise:

___No

___Yes Type: ________________ How Often:____________________

FAMILY HEALTH REVIEW:

Does anyone in your family have multiple sclerosis or another autoimmune disease (e.g., Multiple Sclerosis, Lupus, Crohn's Disease,Rheumatoid Arthritis, etc.)? If so, whom?

______________________________________________________________________________ ______________________________________________________________________________

Please list any health problems that have occurred in your family and which family members are/were affected.

______________________________________________________________________________ ______________________________________________________________________________

~  6  ~  

Multiple Sclerosis Center of Nebraska Intake Form (continued) Review of Systems

Please place an “x” next to current or recently experienced symptoms: ___ Fevers/Sweats/Chills ___ Blood in urine ___ Unexplained weight loss/gain ___ Pain with urination ___ Fatigue/Lethargy ___ Bladder Problems

___ Sleep Problems ___ Gynecological Problems and/or sexual problems

___Vision Change ___ Abnormal menstruation

___ Discharge in Eye(s) ___ Breast lump or discharge

___ Pain with eye globe movement ___ Erectile Problems and/or other sexual problems ___ Pain with eye globe movement ___genital ulcers

___ Excessive dryness/tearing problems ___frequent urinary infections

___ Cataract ___ Joint pain

___ Lazy eye ___ Joint swelling or redness ___ Bleached out color perception ___ Tender muscles

___ Gray areas or black holes in vision ___ Back or neck pain ___ Sinus problems/Nasal Congestion/Cough/Runny Nose ___ Skin Cancer

___ Hearing loss ___ Rash/Skin Discoloration ___ Ear fullness or pain ___ Injection site lumps ___ Ringing or buzzing in ears ___ Injection site pain/red ___ Sores on tongue/gums/mouth ___ Seizures

___ Problem with teeth ___ Loss of consciousness ___ Trouble swallowing ___ Dizziness/light headed

___ Hoarseness ___ Dizziness/Vertigo

___Sore Throat ___ Headaches

___ Chest pain/discomfort ___ Racing thoughts/Anxiety ___ Palpitations or irregular heart beat ___ Poor mood/Depression ___ Shortness of breath/wheezing ___ Suicidal thoughts

___Cough ___ Easy bruising/bleeding

___ Frequent nausea or vomiting ___ Enlarged lymph glands/Swollen ___ Heartburn/Reflux Glands

___ Stomach Pain ___Swelling of Extremities

___ Dark/Tarry looking stool ___Difficulty with Balance/Coordination ___ Bright red blood in stool ___Numbness/Weakness

___ Constipation ___Abdominal Pain/Swelling/Bloating

___Diarrhea ___Any changes in your ability to think or understand things

Please list any other symptoms you are experiencing or have recently experienced:

________________________________________________________________________________ ________________________________________________________________________________