The newest package to be used.

Neurology Headache and Pain Clinic
Sachin R. Shenoy, M.D.
Board Certified in Neurology and Pain Management
Social security # _______________________ Cell Phone ____________________________ Best Phone # to call (please circle) Home Cell Referred By (Please List): Physician _________________________ Friend_________ Family _______________ Heard about us from _____ Newspaper ____ Yellow Pages _______Radio _____ Internet ________ Mailing address _________________________________________________ Have you ever seen Dr. Shenoy prior to today for any medical reason? Yes / No Employer __________________________________ Local person to contact in case of emergency ___________________ Phone # _______________________________ Primary Insurance _________________________ Card Holders Name ________________________________ Secondary Insurance ___________________________ Card Holders Name ________________________________ HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA) (ALL PATIENTS MUST
I acknowledge that I have been given the opportunity to read the Heath Insurance Portability and Accountability Act of 1996 (HIPAA), and I agree to the terms set forth. Please Note: If your copy is missing there is a copy on the wall to the left of the check in window. X__________________________________________________________________________________________________ AUTHORIZATION FOR US TO BILL MEDICARE FOR YOUR VISITS
I authorize payment of Medicare benefits to Sachin R. Shenoy MD, PA I authorize the release/transmission of pertinent medical information necessary to determine benefits. I realize that I am responsible for deductibles, co-payments, and non-covered X _____________________________________________________________________________________________________ AUTHORIZATION FOR US TO BILL YOUR COMMERCIAL OR SECONDARY INSURANCE FOR YOUR VISITS
I authorize payment of insurance benefits directly to Sachin R. Shenoy MD, PA and the release/transmission of pertinent medical information necessary to determine benefits. I am responsible for all charges not covered by insurance contracts, including co-payments, deductibles, non-covered services, and those determined by the insurance company to be above their X _________________________________________________________________________________________________ 1845 Jess Parrish Ct. Titusville, FL 32796
Phone (321) 264-2011 Fax (321) 264-0442 Page | 1
Neurology Headache and Pain Clinic
Sachin R. Shenoy, M.D.
Board Certified in Neurology and Pain Management
Patient name___________________________________________ PLEASE DESCRIBE YOUR PROBLEM IN A FEW WORDS:
_______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ PAST MEDICAL HISTORY
If yes, please name type of Cancer _________________________________________ Please List_____________________________ PAST SURGICAL HISTORY
NO PRIOR SURGERIES ____ (Please proceed to next paragraph) Tonsillectomy If yes, date(s)__________Type of surgery done _________________________ If yes, date(s)__________ Type of surgery done _________________________ If yes, date(s)__________ Type of surgery done _________________________ Please list any additional surgeries and date__________________________________________________________________
PERSONAL HISTORY

Marital Status: Single _____ Married _____ Divorced _____ Widowed
If In the past when did you stop, what and how much did you consume ____________________ If In the past when did you stop, what and how much did you consume ____________________ If In the past when did you stop, what and how much did you consume ____________________ 1845 Jess Parrish Ct. Titusville, FL 32796
Phone (321) 264-2011 Fax (321) 264-0442 Page | 2
Neurology Headache and Pain Clinic
Sachin R. Shenoy, M.D.
Board Certified in Neurology and Pain Management

FAMILY HISTORY
Major Illnesses _____________________________________ Major Illnesses _____________________________________ ___________________________________________________________________________________ ____________________________________________________________________________________ ___________________________________________________________________________________
Medications and dosage: (Please list all medications, dosages, and indicate how often you take the medication.)
1)
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Please List any allergies that you have

1.____________________________________________________________
2.____________________________________________________________
3.____________________________________________________________
4.____________________________________________________________
1845 Jess Parrish Ct. Titusville, FL 32796
Phone (321) 264-2011 Fax (321) 264-0442 Page | 3
Neurology Headache and Pain Clinic
Sachin R. Shenoy, M.D.
Board Certified in Neurology and Pain Management

Please indicate any if you have
had any of the symptoms
mentioned below in the last
Stomach related
three months by circling the yes
response. If you have not had
Nervous system symptoms
the symptom listed below please
do not circle.
General Symptoms
Urination and Sexual symptoms
Psychiatric
Ears/Nose/Mouth/Throat
Muscle and joint related
Hormone related
Heart related
Skin and Breast
Blood related
Lung related
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information
can be dangerous to my health. It is my responsibility to inform the doctor’s office of any changes in my medical status. I authorize the
healthcare staff to perform the necessary services I may need. I authorize Dr Shenoy and his staff to release to a physician/s of my choosing and
to discuss my care with him/ her / them as needed. I also give Dr Shenoy permission to discuss my health issues with my prior treating
physicians if needed. . I also authorize Dr Shenoy and or members of his staff to discuss my information as required by law with any law
enforcement agency or other enforcement agencies if required by law.


__________________________________________________________________________________________________
______________________________________________________
Signature of Patient or Parent or Legal Guardian
1845 Jess Parrish Ct. Titusville, FL 32796
Phone (321) 264-2011 Fax (321) 264-0442 Page | 4
Neurology, Headache, and Pain Management Clinic 1845 Jess Parrish Ct, Titusvil e, Fl 32796 Authorization To Release Medical Records
I, ______________________________________________, do hereby consent and authorize
Dr. Sachin Shenoy to disclose to _____________________________________________
information from my medical records relating to identity, diagnosis, prognosis, or treatment,
including psychiatric disorders and substance abuse, results of HIV testing, diagnosis of
Acquired Immune Deficiency Syndrome and diagnoses related to AIDS. I understand that the
specific type of information to be released includes: medical records, x-ray reports,
laboratory reports, admissions, consults, operative notes, and discharge summaries, and that
the purpose or need for this disclosure is to continue medical care and/or provide
information to the other parties as named above at my request.
________________________________
____________________________
Signature of patient, legal guardian, or _______________________________
____________________________
Phone _____ - _____ - _______
Fax _____ - _____ - _______
Attention ________________________
Neurology, Headache, and Pain Management Clinic 1845 Jess Parrish Ct, Titusvil e, Fl 32796 Patient Request and Authorization To Release Medical Records
I, ______________________________________________, do hereby consent and authorize
_________________________________________ to disclose to Dr. Sachin Shenoy
information from my medical records relating to identity, diagnosis, prognosis, or treatment,
including psychiatric disorders and substance abuse, results of HIV testing, diagnosis of
Acquired Immune Deficiency Syndrome and diagnoses related to AIDS. I understand that the
specific type of information to be released includes: medical records, x-ray reports,
laboratory reports, admissions, consults, operative notes, and discharge summaries, and that
the purpose or need for this disclosure is to continue medical care and/or provide
information to the other parties as named above at my request.
________________________________
____________________________
Signature of patient, legal guardian, or _______________________________
____________________________
Phone _____ - _____ - _______
Fax _____ - _____ - _______
Attention ________________________
Board Certified in Adult Neurology and Pain Management
Patient Name: ___________________________________________ Date:_____________________
If you have been on or tried any of the medications below, please circle. If a medication has worked for you in the past please indicate so it can possibly be tried again. Please also list side effects next to the medication if any are known.
Anti-Depressants
Sedative- Hypnotics
SSRI’s
Chlordiazepoxide hydrochloride (Librium)
SNRI’s
MAO Inhibitors
NSAID’s
Narcotic Analgesics
Non-Narcotic Analgesics
Beta-Blockers
Hydrocodone (Lortab,Lorcet) Carvedilol (Coreg) Migraine Medications
Muscle Relaxants
Epileptic Medications
Multiple Sclerosis
1845 Jess Parrish Ct, Titusvil e, FL 32796 (P) 321-264-2011 (F) 321-264-0442

Source: http://www.drshenoy.com/assets/Migraine%20Packet.pdf