Get Usc Department Of Neurology Intake Form Date ...

Filling out the USC Department of Neurology Intake Form online provides a convenient way to share important health information. This guide will walk you through each section of the form, ensuring you complete it accurately and efficiently.

Follow the steps to successfully complete the intake form.

1. Click the ‘Get Form’ button to access the intake form and open it in your preferred digital workspace.
2. Begin by entering the date at the top of the form. This helps to track the timing of your visit.
3. Fill in your name and date of birth accurately. This information is critical for identification purposes.
4. Indicate your age, as this information is relevant to your medical history.
5. Provide your Social Security Number. This may be required for insurance and identification.
6. Select your gender by marking either 'Male' or 'Female.' If you prefer not to specify, you may leave this section blank.
7. Enter your address, including city, state, and zip code for geographic identification and contact purposes.
8. Provide your contact phone numbers, indicating home, work, and mobile numbers, as necessary.
9. Specify the best number to reach you in case of follow-up questions or discussions.
10. List the referring physician’s name and their contact phone number for further coordination of care.
11. Enter your primary care physician’s name and their contact number.
12. Indicate your occupation, which can provide context for your medical condition.
13. Answer whether this visit is related to Worker’s Compensation by selecting 'Yes' or 'No.'
14. List your symptoms in order of importance to help prioritize your care.
15. In the past medical history section, itemize any prior neurological diagnoses followed by any other medical conditions or surgeries.
16. Indicate your claustrophobic status and whether you have metal in your body as these may be critical for certain examinations.
17. Provide your current weight for medical assessment.
18. In the social history section, indicate your marital status and employment status. If employed, provide your employer's name and your tobacco use habits.
19. Share your alcohol consumption by noting the average number of drinks per day and days per week.
20. Indicate your caffeine intake and whether you use street drugs.
21. Complete the sleep section by stating your average hours of sleep per night.
22. In the family history section, list any medical conditions diagnosed in your immediate family members.
23. Document any hereditary neurological diseases within your family.
24. Finally, in the allergies section, specify if you have any medication allergies and whether you are allergic to contrast dye. If applicable, provide details.
25. Once you have completed all sections of the form, you can save your changes, download the form, print it, or share it as necessary.

Complete your USC Department of Neurology Intake Form online for a smoother healthcare experience.