WPC MW&ٺv!30n,xP;Y?\pÜY}D_;˱ҷzNcqfA&UO.V̔0Ogio`-CW w0w8a;kGnhNQ]$$ojM~Bz9!V?䴩n^F\T+չ8=`uu*eXI@b75?ĀIф}uVX!cIR$'<00,>=3+@H)ݘ]6lGK(s#zomrP 0U&0 0 0  0< " " UB+ m 0} #3 UN %BMH(LNt^ vw4 m\  `&Times New Roman' MARK DIETZ MD Shepard0Shepard .   6 4Heading 1E*jp`GaramondE   ,"X X _p x (#%,     D:XX` hp x (#%DS\  `&Times New RomanS *jp`Garamond6 4Heading 2XXXE*jp`GaramondE '  $!(#%    G=XX` hp x (#%GS\  `&Times New RomanS 6k l4Heading 3XXXE*jp`GaramondE   S\  `&Times New RomanS<:Default Para          *jp`*Bookman Old Style#|x($XX..      >XX>>HP OfficeJet R Series0(,,,,0(0(9 Z6Times New Roman RegularXV'y*L B(8]U  !XX..      +_XX+_+_  _         6"X X {p x (#%X68+_8 CHARLESANDERSONMD  AdultNeurologist  MedicalSpecialistsofHelena ~ 2525BroadwaySuite200 { Helena,MT.59601 x 406-457-4343 u   B"X X _p x (#%XX {pX%B    B"X X {p x (#%XX _pX%B&  o  Fax#406-457-4344ot  Ԍ r  Ќ  6XX {pX%XX {pX%6    'r h<XX{ x (#%XX {pX%<Yourappointmentisscheduledfor_________________________ l  At___________________________________ i      T4XX` hp x (#%XX{ X%TYouhavebeenscheduledforaneurologicconsultation.Pleasecompletethismedicalhistory c  questionnaireBEFOREyourscheduledappointmentandbringitwithyouwhenyoucome.Ifeelthis `  informationisessentialtoathoroughevaluation,anditscompletionwillallowusmoretimefora ]  detaileddiscussionofyourmainproblem. Z  ItisnecessarythatyouhaveaprimaryphysiciantowhomIwillsendyourconsultationreport W andwhowillprovidelong-termfollowupcare.Iamavailableforcareduringclinichoursandifyou T havequestionsorareexperiencingsomeproblemsyouwouldliketodiscuss,pleasecall.Afterhours, Q holidays,andweekendsyouwillneedtocontactyourprimaryphysician. N      ______Youhavebeenscheduledfornerveconductionstudiesandelectromyography.Pleasereadthe H enclosedbookletaboutthesetests,whichshouldtakeabout60-90minutes.Youdonotneedto E completeaquestionnaire. B     ______YouhavebeenscheduledforascreeningtestforCarpalTunnelSyndrome.Pleasereadthe < enclosedbookletaboutthenerveconductionstudies.Thisscreeningtestdoesnotinclude 9 electromyography,andshouldtakeapproximately20-30minutes. 6     Q4XX` hp x (#%XXX%QMyofficeislocatedonthesecondfloorofthenewMariaDeanMedicalBuildinginSuite200eastof 0 St.Peter'sHospital.IrecommendthatyouusethenorthentrancefacingBroadway,andtakethe -  elevatortosecondfloor. *!   '"       Name:____________________________________________  Please BRIEFLY describetheproblemforwhichyouhavebeenreferred:___________________ ~ _____________________________________________________________________________ { _____________________________________________________________________________ x _____________________________________________________________________________ u _____________________________________________________________________________ r  _____________________________________________________________________________ o  _____________________________________________________________________________ l  _____________________________________________________________________________ i   Please CIRCLE anyofthefollowingconditionsyouhavehadandprovidea BRIEF explanationin c  theareaimmediatelybelow4: Diabetes h Cancer  HighBloodPressureHeartDiseaseHighCholesterol `       `  ThyroiddiseaseLungDiseaseUlcersHeadInjury ]       `  MentalIllnessOtherMajorIllnesses:X%X4 ___________________________   ______________________________________________________________________________________ u ______________________________________________________________________________________ V ______________________________________________________________________________________ 7 ______________________________________________________________________________________  ______________________________________________________________________________________ } ______________________________________________________________________________________ ^ ______________________________________________________________________________________ ? ______________________________________________________________________________________   Pleaselistanyprevioussurgeriesyouhavehad(ifmorespaceisneeded,usebackofpage)"] XX%:_____________ ^ __________________________________________________________________________ d __________________________________________________________________________ j __________________________________________________________________________ p __________________________________________________________________________ v __________________________________________________________________________ | __________________________________________________________________________   __________________________________________________________________________  ! X%X "]Pleaselist ALL ofyourcurrentmedications AND theirdosages,ifknown:_____________________________ #! _______________________________________________________________________________________ #u " _______________________________________________________________________________________ $V!# _______________________________________________________________________________________ %7"$ _______________________________________________________________________________________ &#% _______________________________________________________________________________________ }'#& Pleaselist DRUG ALLERGIES ,ifany:_______________________________________________________ ?)%( ________________________________________________________________________________________  *&) X%XXX%X%XXX%    &  #  Haveyoubeenasmoker?__________Howmanypackperday?_______________Howmanyyears?_______#  qԌ +}'* ЌX%XXX%X%XXX%  Doyoustillsmoke?___________Ifno,whendidyouquit?________________'+ +^(+ Doyoudrinkalcoholicbeverages?__________________ifno,haveyoudonesointhepast?_____________ ,?), IfYouDOdrink,approximatelyhowmanydrinksPERWEEKmightyouhave?______________________ - *- "] XX%  .+. X%X "]XX Hasanyoneinyourfamilyhadanyofthefollowingconditions?Please CIRCLE thosethatapply e andexplaininthespaceprovidedimmediatelybelow: F  0 W/ (#XXX%0 Stroke EpilepsyorseizuresTremor  HeartDiseaseHeadache   < W/ (# W/ (#<X%XXX%X%XXX% '9$!(#% W/ (#9    &  S#  Brainhemorrhage(oraneurysm) | OtherdisordersofmusclesornervesS#$  #Ԍ F Ќ '9 W/ (#$!(#%9X%XXX%X%XXX%  3|(# W/ (#3______________________________________________________________________________'$  ' ______________________________________________________________________________   ______________________________________________________________________________ m   H.` hp x (#|(#HHaveyouhadanyofthesymptomslistedbelow?Ifso, CIRCLE themandgivea BRIEF  /  explanationinthespaceprovided:    ( XX%Headache: m  Dizziness:   RingingintheEars: ?  HearingLoss: f ChangesinSpeech:   Blackouts: 0 Numbness: W Weakness: ~ TroubleSwallowing: ) TroubleWalking: P DoubleVision: w! LossofVision: # Nervousness: A% Irritability: h' Depression: ) LossofEnergy: : + MemoryLoss: a!- RecentWeightChange: "/ ChangeofAppetite: #+ 1 TroubleSleeping: $R!3 ExcessiveSnoring: %y"5 ChestPains: $'#7 ShortnessofBreath: K($9 AbdominalPain: r)%; BleedinginUrineorStool: *'= Constipation:Diarrhea: +<(? DifficultyHoldingorPassingUrine: ,c)A  IMPORTANTFORYOUNGFEMALES: 󀀀Areyoupregnant? .*C   6 p x (#X(#6Ifnot,areyoutakingbirthcontrolpills?  .O+D           6 - x (#X(#6   (   HELENAMEDICALSPECIALISTS  MARIADEANBUILDING 4 2525BROADWAY ` HELENA,MT59601    0 (# -X(#0CHARLESB.ANDERSON,M.D.  KENNETHV.EDEN,M.D. p ADULTNEUROLOGY  GASTROENTEROLOGY   MARKDIETZ,M.D.  JEFFREYDICKERSON,M.D.   ADULTNEUROLOGY  PULMONOLOGY  0  ARTHURSNYDER,M.D.    RHEUMATOLOGY  @    6ZZZ x (# A6BILLINGINFORMATION $    <Z x (#ZZZX(#< X$X  X%XX X$    N.` hp x (#ZX(#N&  0  4XX% IFYOUARECOVEREDBYMEDICAID #X%X41#0k1  0Ԍ   Ќ XX%     [E. ` hp x (#X(#EYOUMUSTPRESENTYOURCURRENTCARDATEACHVISIT.YOURPHYSICIANHASTHE ?  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