Dysautonomia-MVP Center - Amazon S3 · Dysautonomia-MVP Center Any physician, sta!, employee or representative of Dysautonomia-MVP Center has my permission to discuss my account and

Dysautonomia-MVP Center2470 Rocky Ridge Road, Ste 200

Birmingham, AL 35243

Dysautonomia-MVP Center

We look forward to seeing you. Please call us if you have any further questions. (205) 286-3200 / (205) 286-3201 Fax.

VISIT OUR WEBSITE AT WWW/MVPCTR.COM



[email protected]



Dysautonomia-MVP CenterDysautonomia-MVP Center


REV. 3/6/15PATIENT INFORMATION

Email:_______________________________________________________________________________________________________



REV. 3/6/15



Phone 205-286-3200 Fax 205-286-3201

[email protected]


2470 Rocky Ridge Road, Ste 200


Phone 205-286-3200 Fax 205-286-3201

D ys autonomia-MVP C enter

(205) 286-3201



[email protected]

REV. 3/6/15


Any physician, staff, employee or representative of Dysautonomia-MVP Center has my permission to discuss my account and medical conditions which may include symptoms, treatments, diagnosis, test results, medications or any other type of protected health information with the following persons:


Birmingham, AL 35243(205)-286-3200

3/06/15

(B) 3/06/15

Effective January 1, 2012, the Dysautonomia-MVP Center will

have a charge for a patient who cancels or does not show

for their appointment.

PATIENT MEDICAL HISTORY FORM

Patient Name (legal): ___________________________________________________________________________________ Date of Birth: _______________________________ Age: ___________ Today’s Date: __________________________ Pharmacy Name: _____________________________________ Pharmacy Tel Number: _____________________________ Referring Physician: __________________________________Primary Physician: _________________________________ Email address: ______________________________________________Occupation:_________________________________

Current Medications

Medication name Dose How often Why do you take this Who prescribes this

Do you get allergy shots? Yes / No Are you allergic to any medications? Yes / No If yes, please list them: ________________________________________________________________________________ ____________________________________________________________________________________________________

Past Medical History: Please check beside any of the conditions that you HAVE BEEN diagnosed with and/or treated for

Heart Disease Lung Disease Epilepsy or Seizures

High Blood Pressure Asthma Irritable Bowel Syndrome

High Cholesterol Seasonal Allergies Gastroparesis

Mitral Valve Prolapse Arthritis Reflux

Diabetes Fibromyalgia Vein Trouble

Kidney Problems Osteoporosis Meniere’s or Vertigo

Thyroid Problems Ehlers-Danlos Syndrome Insomnia

Shortness of Breath Anemia Narcolepsy

Nervous Disorder Stroke Cancer

Migraines Bleeding Disorders If yes, which type? _______________

Other Medical Conditions (please list): ____________________________________________________________________ _____________________________________________________________________________________________________

Past Surgical History: Please list any surgeries you have had in the past:

Date Type of Surgery Surgeon (if known)

2470 ROCKY RIDGE RD, STE 200 BIRMINGHAM, AL 35243

P: (205) 286-3200 F: (205) 286-3201

DYSAUTONOMIA-MVP CENTER, LLC DR. PAULA MOORE/DR. SUSAN PHILLIPS

Past Hospitalization: Please list any hospitalizations other than for surgeries already listed:

Reason Date

Family History

Medical Condition Type Mother Father Sister(s) Brother(s)

Cancer

Heart Disease

Diabetes

Mental Conditions

Thyroid Disorder

List any other pertinent family medical history: _________________________________________________________ _________________________________________________________________________________________________

• Is your mother alive? Yes / No (age at death: ____ ; cause: _____________________)

• Is your father alive? Yes / No (age at death: ____ ; cause: ______________________) Social History: Marital Status: Single / Married / Divorced / Separated / Widowed Children: Yes / No; If yes, how many _________ / Year of birth of each: __________________________ Smoking Status: Do you smoke or use tobacco: Yes / No; If yes: cigarettes / cigars / chewing tobacco / vape How much do you smoke? _____________ / day; ______________/ week Alcohol: Do you drink alcohol: Yes / No If yes, how much: _______ drinks per day; ______ drinks per week Caffeine intake: Yes / No If yes: ______ cups coffee / tea per day Carbonated caffeine beverages: _____ / day Fluid intake: How much fluid do you drink per day? _______________________ / cups or oz Exercise history: Do you exercise: Yes / No If yes, how much: ______minutes / day; _______days / week Please circle any of the following conditions you CURRENTLY experience: Allergies / Insomnia / Sleep apnea / Narcolepsy / Excessive sleepiness / Personal Cancer history: if yes, where_______________________ / fatigue /weight loss Vertigo / Hearing loss / Ringing in ears Goiter / hypothyroidism / hyperthyroidism / diabetes: type I or II Syncope (passing out) / Lightheadedness / Tachycardia (fast heart rate) / Heart attack / High cholesterol / Chest pain /High blood pressure / Palpitations / shortness of breath Abdominal bloating / IBS / Abdominal pain / Constipation / Diarrhea Pain in joints / Muscle pains / Fibromyalgia / Ehlers-Danlos Syndrome / Arthritis Migraines / Dizziness / Tingling and numbness Psychiatric meds in the past? Yes / No / Bipolar disorder / Anxiety / Depression Asthma / cough / wheezing Blurred vision / dry eyes / floaters in eyes *** Patient signature: _______________________________________________ Date: ______________________ ***

*** You must sign this form ***

Documents

Dysautonomia-MVP Center - Amazon S3 · Dysautonomia-MVP Center Any physician, sta!, employee or representative of Dysautonomia-MVP Center has my permission to discuss my account and