CHARLES ANDERSON MD

Adult Neurologist

Medical Specialists of Helena

2525 Broadway Suite 200

Helena, MT. 59601

406‑457‑4343

Fax # 406‑457‑4344

Your appointment is scheduled for _________________________

At ___________________________________

You have been scheduled for a neurologic consultation. Please complete this medical history questionnaire BEFORE your scheduled appointment and bring it with you when you come. I feel this information is essential to a thorough evaluation, and its completion will allow us more time for a detailed discussion of your main problem.

It is necessary that you have a primary physician to whom I will send your consultation report and who will provide long‑term follow up care. I am available for care during clinic hours and if you have questions or are experiencing some problems you would like to discuss, please call. After hours, holidays, and weekends you will need to contact your primary physician.

______You have been scheduled for nerve conduction studies and electromyography. Please read the enclosed booklet about these tests, which should take about 60‑90 minutes. You do not need to complete a questionnaire.

______You have been scheduled for a screening test for Carpal Tunnel Syndrome. Please read the enclosed booklet about the nerve conduction studies. This screening test does not include electromyography, and should take approximately 20‑30 minutes.

My office is located on the second floor of the new Maria Dean Medical Building in Suite 200 east of St. Peter's Hospital. I recommend that you use the north entrance facing Broadway, and take the elevator to second floor.

Name: ____________________________________________

Please BRIEFLY describe the problem for which you have been referred: ___________________

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Please CIRCLE any of the following conditions you have had and provide a BRIEF explanation in the area immediately below: Diabetes Cancer High Blood Pressure Heart Disease High Cholesterol

Thyroid disease Lung Disease Ulcers Head Injury

Mental Illness Other Major Illnesses: ___________________________

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Please list any previous surgeries you have had (if more space is needed, use back of page): _____________

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Please list ALL of your current medications AND their dosages, if known: _____________________________

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Please list DRUG ALLERGIES, if any: _______________________________________________________

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Have you been a smoker? __ How many pack per day? _ How many years? _

Do you still smoke? ___________ If no, when did you quit? ________________

Do you drink alcoholic beverages? __________________ if no, have you done so in the past? _____________

If You DO drink, approximately how many drinks PER WEEK might you have? ______________________

Has anyone in your family had any of the following conditions? Please CIRCLE those that apply and explain in the space provided immediately below:

Stroke Epilepsy or seizures Tremor Heart Disease Headache

Brain hemorrhage (or aneurysm) Other disorders of muscles or nerves

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Have you had any of the symptoms listed below? If so, CIRCLE them and give a BRIEF explanation in the space provided:

Headache:

Dizziness:

Ringing in the Ears:

Hearing Loss:

Changes in Speech:

Blackouts:

Numbness:

Weakness:

Trouble Swallowing:

Trouble Walking:

Double Vision:

Loss of Vision:

Nervousness:

Irritability:

Depression:

Loss of Energy:

Memory Loss:

Recent Weight Change:

Change of Appetite:

Trouble Sleeping:

Excessive Snoring:

Chest Pains:

Shortness of Breath:

Abdominal Pain:

Bleeding in Urine or Stool:

Constipation: Diarrhea:

Difficulty Holding or Passing Urine:

IMPORTANT FOR YOUNG FEMALES: Are you pregnant?

If not, are you taking birth control pills?

HELENA MEDICAL SPECIALISTS

MARIA DEAN BUILDING

2525 BROADWAY

HELENA, MT 59601

CHARLES B. ANDERSON, M.D. KENNETH V. EDEN, M.D.

ADULT NEUROLOGY GASTROENTEROLOGY

MARK DIETZ, M.D. JEFFREY DICKERSON, M.D.

ADULT NEUROLOGY PULMONOLOGY

ARTHUR SNYDER, M.D.

RHEUMATOLOGY

BILLING INFORMATION

IF YOU ARE COVERED BY MEDICAID

YOU MUST PRESENT YOUR CURRENT CARD AT EACH VISIT. YOUR PHYSICIAN HAS THE RIGHT TO REFUSE SERVICES IF YOU DO NOT HAVE YOUR CARD.

IF YOU ARE COVERED BY WORKER'S COMPENSATION

YOU MUST BRING YOUR CLAIM NUMBER, DATE OF INJURY, AND THE NAME OF THE WORKER'S COMPENSATION AGENCY. THIS INFORMATION CAN BE OBTAINED THROUGH YOUR EMPLOYER OR YOUR WORKER'S COMPENSATION AGENT. AS THE PATIENT RECEIVING SERVICES, YOU ARE ULTIMATELY RESPONSIBLE FOR PAYMENT SHOULD WORKER'S COMPENSATION COVERAGE BE DENIED.

IF YOU ARE COVERED BY MEDICARE OR OTHER PERSONAL INSURANCE PLANS

PLEASE BRING YOUR INSURANCE CARD AND ANY OTHER INFORMATION THAT MAY BE HELPFUL FOR OUR BILLING OFFICE.

OUR BILLING OFFICE WILL GLADLY SUBMIT YOUR CLAIM TO YOUR INSURANCE COMPANY, PROVIDED WE HAVE ALL THE NECESSARY INFORAMTION. IF YOU DO NOT HAVE ANY INSURANCE COVERAGE WE ASK THAT YOU CONTACT OUR BILLING OFFICE TO SET UP PAYMENT ARRANGEMENTS. IF YOU HAVE ANY QUESTIONS REGARDING THE ABOVE INFORMATION PLEASE CONTACT OUR OFFICE.

I UNDERSTAND THAT THE ABOVE INFORMATION IS NECESSARY IN ORDER TO PROCESS MY CLAIM.