<p>2841 Debarr Road, Suite 32, Anchorage, AK 99508 Tel. 907.331.3640 3831 Piper Street, Suite SLL020, Anchorage, AK, 99508 Fax: 907.331.3647</p><p>*Please bring completed forms to your office visit or fax them to (907) 331-3647. Thank you* PATIENT INFORMATION Name: ______Today’s Date: ______Date of Birth: ______SSN: ______Mailing Address: ______Unit / Apt #: ______City: ______State: ______Zip Code: ______Phone: ______home / mobile / work E-mail: ______Language: ______Ethnicity: ______Emergency Contact Person (not living with you): ______Relationship: ______Phone Number: ______Pharmacy Name: ______Phone Number: ______INSURANCE INFORMATION Primary Insurance Coverage: ______Claims Mailing Address: ______Insurance Company Phone: ______Policy #: ______Group #: ______Policy Holder’s Name: ______Policy Holder Date of Birth: ______Policy Holder’s SSN#: ______Relationship to Patient: ______Secondary Insurance Coverage: ______Claims Mailing Address: ______Insurance Company Phone: ______Policy #: ______Group #: ______Policy Holder’s Name: ______Policy Holder Date of Birth: ______Policy Holder’s SSN#: ______Relationship to Patient: ______You can access our patient portal at www.peakneurology.com and gain full access to your medical history. You can also message your provider, request prescription refills, update your personal information, and receive a care summary after your visit.</p><p>Page 1 of 5 PEAK Intake Form Please bring to your visit or fax to 907.331.3647 PAST MEDICAL HISTORY INTAKE</p><p>Who referred you to our office? ______Who is your Primary Care Physician? (If different than referring provider) ______Are there any other physicians who should have receive correspondence regarding your care? ______Chief complaint (why are you here today?) ______Have you or has any family member experienced any of the following? Please check the appropriate box: Self Mother Father Sister Brother Acid Reflux Asthma COPD Chronic pain Depression/Mental Illness Diabetes Headaches/Migraines Heart Disease, Heart Surgery</p><p>Congestive Heart Failure</p><p>High Blood Pressure</p><p>Atrial Fibrillation Kidney disease Sleep Apnea Stroke or Warning Stroke Substance Abuse Other</p><p>List any additional medical problems that you have ______Are you pregnant or breastfeeding? Yes / no. When was your last Menstrual Cycle? ______</p><p>MAJOR HOSPITALIZATIONS AND SURGERIES Year Operation or Illness Name of Hospital City and State </p><p>LIST OF CURRENT MEDICATIONS Please list all current medications including medications that you take on an as needed basis. Please be sure to include supplements and other over the counter or naturopathic medications. </p><p>Page 2 of 5 PEAK Intake Form Please bring to your visit or fax to 907.331.3647 Name of Medication Strength/Do How many do you take, and how often do you take? se</p><p>Allergies to Medications: Please list each allergy and the reaction you had to that medicine. </p><p>Medication Reaction</p><p>SOCIAL HISTORY</p><p>Do you smoke? Yes / no If yes, write type and amount per day: ______</p><p>Occupation: ______Marital status (circle one): Single Married Divorced Widowed </p><p>How many children do you have, and how old are they? ______</p><p>Do you consume alcohol? Yes / no If yes, write type and amount per week: ______</p><p>If no, did you previously drink alcohol? Yes/ no If yes, when did you quit?______</p><p>Do you chew tobacco? Yes / no If yes, write frequency ______</p><p>Do you smoke cigarettes? Yes/ no If yes, how many packs per day? ______</p><p>If no, did you previously smoke cigarettes? Yes/ no If yes when did you quit? ______</p><p>Do you consume caffeine (including caffeinated beverages such as energy drinks, coffee, tea, or cola)? If Page 3 of 5 PEAK Intake Form Please bring to your visit or fax to 907.331.3647 yes, write type and frequency ______</p><p>Do you exercise? Yes / no If yes, write type and frequency: ______</p><p>What time do you usually eat your last meal of the day? ______</p><p>REVIEW OF SYSTEMS Please circle any of the following illnesses or problems you have had in the last 12 months:</p><p>Constitutional Normal Malnourished Musculoskeletal Normal Muscle cramps </p><p>Fever Chills Recent weight change Joint stiffness/swelling Weakness Back/Joint pain Eyes Normal Blurred or double vision Integumentary (skin) Normal Dry skin Rash </p><p>Blindness Corrective lenses Dry eyes Change in color of skin Varicose veins Ears/Nose/Throat Normal Hearing loss Allergic/Immunologic No allergies </p><p>Hoarseness Nosebleed Chronic nasal Food allergy Medication allergy </p><p> congestion Immune deficiency Cardiovascular Normal Chest pain Endocrine Normal Excessive thirst </p><p>Irregular rhythm Palpitations Swelling of Temperature intolerance Diabetes </p><p> extremities High blood pressure Excessive hunger Hormone deficiency</p><p>Page 4 of 5 PEAK Intake Form Please bring to your visit or fax to 907.331.3647 Respiratory Normal Chronic cough Hematological/Lymph Normal Anemia Easy Wheezing Shortness of breath COPD bruising/bleeding Swollen lymph nodes Asthma Tuberculosis Gastro-Intestinal Normal Abdominal pain Neurological Normal Numbness Headache </p><p>Nausea Vomiting Diarrhea Constipation Dizziness Stroke Seizures Fainting </p><p>Rectal bleeding Difficulty swallowing Migraines Paralysis Tremor Dementia </p><p>Jaundice Heartburn Memory loss/Confusion Genito-Urinary Normal Blood in urine Psychological Normal Depression Anxiety </p><p>Pain during urination Voiding urgency Insomnia Substance abuse</p><p>Pelvic pain Bedwetting/accidents </p><p>Menstrual pain Bladder incontinence I verify that the above information is true and accurate to the best of my knowledge. X______Signature of patient (or parent if patient is a minor) Date</p><p>Page 5 of 5 PEAK Intake Form Please bring to your visit or fax to 907.331.3647</p>