WPC M.XC&$pC uГ8C_`_8*m ^{@j,Ro؞RZq*&qKy($T["7S)]s3Po=%Gh?ޟ/Z\ZAr2Az >g 6ȶXwnna]6}cúl.90ؕӾy{# >!"j`ݭ*Z{[!W!YDko+>:AZѱd&$ߒ)Zj[ngi6t#0@*t=yO,Ѿn;M4f=,Q"hS!8za>ЋoakHHCz}f`ЯIy&R}|W&(7aA{$5qeݤǑ,wh 3DO} P 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 '  $!(#%    G=XX` hp x (#%GS\  `&Times New RomanS 6k l4Heading 3XXXE*jp`GaramondE   S\  `&Times New RomanS<:Default Para          *jp`*Bookman Old Style#|x(d$XX..      !XX!!HP OfficeJet R Series0(,,,,0(0(9 Z6Times New Roman RegularX&y*L B(4U  d!XX..      !XX!!  _         6"X X _p x (#%X6*!* MARKDIETZMD  AdultNeurologist  MedicalSpecialistsofHelena ~ 2525 BroadwaySuite200 { Helena,MT.59601 x 406-457-4343 u   B"X X _p x (#%XX _pX%B    &  o  Fax#406-457-4344o2  Ԍ r  Ќ  6XX _pX%XX _pX%6    'r &<XXx x (#%XX _pX%<Yourappointmentisscheduledfor__________________________________________ l  At______________________________________ i      T4XX` hp x (#%XXx 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  theareaimmediatelybelow: Diabetes h Cancer  HighBloodPressureHeartDiseaseHighCholesterol `       `  ThyroiddiseaseLungDiseaseUlcersHeadInjury ]       `  MentalIllnessOtherMajorIllnesses:X2X ___________________________   ______________________________________________________________________________________ u ______________________________________________________________________________________ V ______________________________________________________________________________________ 7 ______________________________________________________________________________________  ______________________________________________________________________________________ } ______________________________________________________________________________________ ^ ______________________________________________________________________________________ ? ______________________________________________________________________________________   Pleaselistanyprevioussurgeriesyouhavehad(ifmorespaceisneeded,usebackofpage) ] XX2:_____________ ^ __________________________________________________________________________ d __________________________________________________________________________ j __________________________________________________________________________ p __________________________________________________________________________ v __________________________________________________________________________ | __________________________________________________________________________   __________________________________________________________________________  ! X2X  ]Pleaselist ALL ofyourcurrentmedications AND theirdosages,ifknown:_____________________________ #! _______________________________________________________________________________________ #u " _______________________________________________________________________________________ $V!# _______________________________________________________________________________________ %7"$ _______________________________________________________________________________________ &#% _______________________________________________________________________________________ }'#& Pleaselist DRUG ALLERGIES ,ifany:_______________________________________________________ ?)%( ________________________________________________________________________________________  *&) X2XXX2X2XXX2    &    Haveyoubeenasmoker?__________Howmanypackperday?_______________Howmanyyears?_______F  "Ԍ +}'* ЌX2XXX2X2XXX2  Doyoustillsmoke?___________Ifno,whendidyouquit?________________'+: +^(+ Doyoudrinkalcoholicbeverages?__________________ifno,haveyoudonesointhepast?_____________ ,?), IfYouDOdrink,approximatelyhowmanydrinksPERWEEKmightyouhave?______________________ - *-  ] XX2  .+. X2X  ]XX Hasanyoneinyourfamilyhadanyofthefollowingconditions?Please CIRCLE thosethatapply e andexplaininthespaceprovidedimmediatelybelow: F  0 W/ (#XXX%0 Stroke EpilepsyorseizuresTremor  HeartDiseaseHeadache   < W/ (# W/ (#<X2XXX2X2XXX2 '9$!(#% W/ (#9    &  #  Brainhemorrhage(oraneurysm) | Otherdisordersofmusclesornerves##  #Ԍ F Ќ '9 W/ (#$!(#%9X2XXX2X2XXX2  3|(# W/ (#3______________________________________________________________________________'#  ' ______________________________________________________________________________   ______________________________________________________________________________ m   H.` hp x (#|(#HHaveyouhadanyofthesymptomslistedbelow?Ifso, CIRCLE themandgivea BRIEF  /  explanationinthespaceprovided:    * XX2Headache: 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$X  X2XX X$    N.` hp x (#ZX(#N&  \0  XX2 IFYOUARECOVEREDBYMEDICAID #X2X;1#\01  0Ԍ   Ќ XX2     [E. ` hp x (#X(#EYOUMUSTPRESENTYOURCURRENTCARDATEACHVISIT.YOURPHYSICIANHASTHE ?  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