Welcome and thank you for choosing the Department of Neurosurgery at Cedars-
Sinai Medical for your healthcare needs.
Our mission is to provide first order clinical care for patients with disorders affecting the
central nervous system, to improve treatments through cutting-edge research and
educate patients, clinicians, scientists and community, ensuring the continuation of
innovations in neuroscience. Depending on the nature of your visit, you may be asked
to complete forms and participate in interviews conducted by members of our dedicated
Patient Care Team. This information is used to develop a plan of care for you.
Attached you will find:
1. Referring Physician Form
2. Patient Health History Form
3. Driving Directions and Parking Information
Please complete items 1 and 2 above and be sure to bring your most recent MRI
scans (all pages of all sets) and medical records related to your current medical
condition. This information is necessary in order to perform a complete and thorough
consultation. We also ask that you bring your current health insurance card and photo
identification card.
Since our office uses an electronic medical record system, we do not maintain any
patient records in our office. When requesting medical records generated by our
medical staff, please contact the Health Information Department at Cedars-Sinai
Medical Center at (310) 423-2259. For copies of your imaging studies or reports,
please call the S. Mark Taper Foundation at Cedars-Sinai Medical Center at (310) 423-
8000, option 2.
As part of our ongoing effort to improve the quality of care and service provided to our
patients and guests, we ask that you complete the service satisfaction survey (provided
to you at the conclusion of your visit) and return it to us in the box provided. Self-
addressed return envelopes are also available upon request for your convenience.
Sincerely,
Keith L. Black, M.D.
Chairman
REFERRING PHYSICIAN FORM
PATIENT NAME ______________________ MRN ____________ NSI MD ___________
HOW WERE YOU REFERRED TO US?
Physician Referral Friend/Family Referral Self Referral Media
1-800 Cedars-1 Publication Internet Other
If referred by physician, please complete: Referring MD Name ____________________________
Address _____________________________ City/State ____________________Zip _______
Tel No (___)______________ Fax No. (___)________________
PLEASE PUT √ (s) IN THE APPROPRIATE BOXES IF YOU WOULD LIKE A LETTER SENT TO ANY OF
THE FOLLOWING:
INTERNIST/FAMILYMD_________________
Address __________________________________
City/State _______________________ Zip ______
Tel No (___)__________ Fax No (___)__________
NEUROSURGEON_______________________
Address ___________________________________
City/State _______________________ Zip ______
Tel No (___)__________ Fax No (___)__________
NEUROLOGIST________________________
Address __________________________________
City/State _______________________ Zip ______
Tel No (___)__________ Fax No (___)__________
PEDIATRICIAN________________________
Address __________________________________
City/State _______________________ Zip ______
Tel No (___)__________ Fax No (___)__________
REHAB MD_____________________________
Address ___________________________________
City/State _______________________ Zip ______
Tel No (___)__________ Fax No (___)__________
NEURO ONCOLOGIST___________________
Address __________________________________
City/State _______________________ Zip ______
Tel No (___)__________ Fax No (___)__________
OTHER MD_____________________________
Address ___________________________________
City/State _______________________ Zip ______
Tel No (___)__________ Fax No (___)__________
OTHER MD_____________________________
Address ___________________________________
City/State _______________________ Zip ______
Tel No (___)__________ Fax No (___)_________
I hereby authorize the Department of Neurosurgery at Cedars-Sinai Medical Center to furnish information to the
physicians identified above.
Print Name of Patient Signature of Patient Date
PATIENT HEALTH HISTORY
PATIENT NAME: ____________________________ DATE OF BIRTH: ___/___/___
DATE OF APPOINTMENT: ____/____/____ DOCTOR’S NAME: ___________________
Reason for today’s visit: _________________________________________________________
Please list any prior major illnesses and /or injuries:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Are you currently experiencing any pain? Yes No Acute Chronic
If yes, please rate your pain ____________ (Scale 0 to 10)
Location and frequency of pain ________________________________________
Are you allergic to any medications? Yes No
If yes, please list medication name(s) and reaction(s) _______________________
__________________________________________________________________
Current Medications
Dose (i.e. mg)
Frequency
Have you ever had problems with anesthesia? Yes No
If yes, please describe problem and drug name: ___________________________
__________________________________________________________________
PROCEDURES and TREATMENTS
Surgeries (Type)
Complications
Page 1 of 7
PATIENT NAME __________________________ MRN ______________________
Radiation Therapy
Start and End Dates
No. of Cycles or Boosts
Chemotherapy
Start and End Dates
No. of Cycles
Do you already possess Directives (i.e. Advance, Power of Attorney) Yes No
(If yes, please bring a copy for your medical records on file to next appointment)
REVIEW of SYSTEMS
Are you currently, or have you had, problems with:
General Circle One
Fever Yes No
Weight Loss Yes No
Weight Gain Yes No
Excessive Fatigue Yes No
Night Sweats Yes No
Eyes
Wear Glasses—Date of Last Exam: _________________ Yes No
Infections Yes No
Injuries Yes No
Glaucoma Yes No
Cataracts Yes No
Floaters Yes No
Left Blindness Yes No
Right Blindness Yes No
Blurred Vision Yes No
Double Vision Yes No
Left Peripheral Vision Loss Yes No
Right Peripheral Vision Loss Yes No
Right or Left Enucleation Yes No
Ear, Nose, Throat and Mouth
Wear Hearing Aids Date of Last Exam: ____________ Yes No
Hearing Loss Yes No
Ear Pain Yes No
Ear Infections Yes No
Ringing In Ears Circle: Left Right Both Yes No
Difficulty or Pain with Swallowing Yes No
Nosebleeds Yes No
Nasal Congestion Yes No
Page 2 of 7
PATIENT NAME ___________________________ MRN ______________________
Ear, Nose, Throat and Mouth Circle One
Nasal Drainage Amount______ Color________ Yes No
Inability to Smell Yes No
Sinus Problems Yes No
Sinus Headaches Yes No
Sore Throats Yes No
Mouth Sores Yes No
Cardiovascular
Chest Pain or Angina—Date of Last EKG: __________ Yes No
Arrythmia Yes No
High Blood Pressure Yes No
Irregular Pulse Yes No
Heart Murmur Yes No
High Cholesterol Yes No
CHF Yes No
CHD Yes No
Swelling in Feet or Hands Yes No
Leg Pain while Walking Yes No
Respiratory
Asthma Yes No
Chronic Cough Yes No
Emphysema Yes No
Shortness of Breath Yes No
Bronchitis Yes No
Pneumonia Yes No
Lung Cancer Yes No
Bloody Sputum Yes No
Date of Last Chest X-ray: _________________
Gastrointestinal
Indigestion Yes No
Nausea Yes No
Vomiting Yes No
Blood in your Vomit Yes No
Liver Disease Yes No
Jaundice Yes No
Abdominal Pain Yes No
Diarrhea Yes No
Constipation Yes No
Appetite Disturbance Yes No
Ulcers Yes No
Gastritis Yes No
Page 3 of 7
PATIENT NAME ___________________________ MRN _________________________
Genitourinary Circle One
Urinary Tract Infections Yes No
Painful Urination Yes No
Blood in your Urine Yes No
Difficulty Starting or Stopping Stream Yes No
Incontinence Yes No
Kidney Stones Yes No
Prostate Cancer (males) Yes No
Endometriosis (females) Yes No
Uterine or Cervical Cancer (females) Yes No
Musculoskeletal
Numbness Yes No
Tingling Yes No
Broken Bones—List: __________________________ Yes No
Arm or Leg Weakness Yes No
Back Pain Yes No
Arm or Leg Pain Yes No
Joint Pain or Swelling Yes No
Arthritis Yes No
Cervical Pain (CP) Yes No
Scoliosis Yes No
Musculosclerosis (MS) Yes No
Achondroplasia Yes No
Spinal Stenosis Yes No
Cerebral Palsy Yes No
Spinabifida Yes No
Integumentary
Skin Disease Yes No
Skin Cancer Yes No
Wound or Incision’s Integrity Yes No
Breast Pain, Tenderness or Swelling (females) Yes No
Nipple Discharge (females) Yes No
Date and Result of Last Mammogram (females) Yes No
Neurological
Balance Disturbance Yes No
Dizziness Yes No
Fainting Spells or “Blacking Out” Yes No
Seizures Date of Last Seizure _______________ Yes No
Sleep Disturbance Yes No
Problems with Your Memory Yes No
Disorientation Yes No
Speech deficits Yes No
Inability to Concentrate Yes No
Face Weakness Yes No
Coordination in Arm and/or Legs Yes No
Page 4 of 7
PATIENT NAME ___________________________ MRN __________________________
List assistant devices used _______________________________________________
List activity restrictions ________________________________________________
Psychiatric Circle One
Anxiety Yes No
Depression Yes No
Panic Attacks Yes No
Hallucinations Yes No
OCD (Obsessive Compulsive Disorder) Yes No
Personality Changes Yes No
Have you ever seen a mental health professional such as psychiatrist, psychologist or councelor?
Yes No
If so, please answer the following:
When ________________________
Why ________________________________________________________
What psychiatric medication _____________________________________
Duration of treatment ___________________________________________
Endocrine
Diabetes Yes No
Thyroid Disease Yes No
Increased Appetite Yes No
Excessive Thirst or Urination Yes No
Hormone Problems Yes No
Cushing’s Disease Yes No
Hematologic/Lymphatic
Anemia Yes No
Hemophilia Yes No
Bleeding Tendencies Yes No
Persistent Swollen Glands or Lymph Nodes Yes No
Blood Transfusion Yes No
If yes, when? __________________
Allergic/Immunologic
Food Allergies Yes No
Inhalant (nasal) Allergies Yes No
Immunologic Disorders Yes No
Pediatric Patients ONLY:
Pregnancy Complication (s): Yes No Describe__________________________
Delivery type (mother): Caesarian section Vaginal Adopted
Delivery Complications Yes No Describe __________________________
Page 5 of 7
PATIENT AME _____________________________ MRN _________________________
PATIENT PROFILE
Family Member
Alive
Deceased
Age
Health Status &
Cause of Death
Has anyone in your family had brain tumor? Yes No
Has anyone in your family had a brain aneurysm? Yes No
Occupation __________________________
Marital Status Single Married Divorced Widowed Other
Do you have children? _________________
Tobacco Use: current previous never Started: _____________
Cigarettes Amt: _____ packs per day
Cigars/pipes Amt: _____ # per week
Smokeless/Chewing Amt: _____ per day
Counseled to quit/cut down: Yes No
Year quit: _____________
Alcohol: Yes No Average drink(s) per day: _______________
Type: _____________ Counseled: Yes No
Drugs: Yes No
Drug Choice: marijuana cocaine crack heroin
illicit RX other: _______________________
Comments: ________________________________________________________
Other:
Passive smoker exposure: Yes No
Caffeine Use (drinks/day) 1 2 3 4 5+
Exercise (times/week): 0 1 2 3 4
5 6 7 >7
Types of Exercise: _______________________________________________
Seatbelt use (%) 0 25 50 75 100
Sun Exposure: frequently occasionally rarely
Living Status/Support Systems:
Housing: apartment Living Status: lives alone
house unable to care for self
condo/townhouse lives w/ family/friend/attendant
other difficult access/steps
home health care
other ____________________
Need Social Services Assess: Yes No
Page 6 of 7
PATEINT NAME ___________________________ MRN _______________________
Patient Rights:
Cultural & Spirituality: No cultural/spiritual issues
Beliefs/Practice Effecting TX: _________________________________________
__________________________________________
Healthcare Decisions: makes own medical decisions
medical decisions made jointly b/w patient/family
family members make major decisions
has advance directive
copy given to CSMC
Family/Self Participation in Care/Recovery:
patient desires to be active in planning care
patient desires family to be active in planning care
patient desires friend to be active in planning care
family able & willing to participate in learning about care
friend able & willing to participate in learning about care
Health Maintenance Considerations:
Current immunizations: Yes No
Exposure to communicable disease discussed: Yes No
Date flu shot rcvd: ______________
Intervention/Notes: _________________________________________________
The above information is accurate to the best of my knowledge.
______________________________________ ______/______/______
Patient Signature Date
I have reviewed the above information with the patient.
______________________________________ ______/______/______
Physician Name (Printed) & Signature Date
______________________________________ ______/______/______
RN Name (Printed) & Signature Date
Page 7 of 7
The Department of Neurosurgery Patient Care Team is dedicated to caring for the
whole person. We recognize that dealing with a medical condition can have a
significant emotional impact on a person’s life. To help us in providing the best care
possible please respond to the following questions.
1. In what manner has your neurological problem caused impairments in your ability to
function at work, socially, or in your routine daily activities?
2. Are you presently experiencing distressing emotional symptoms, such as:
_____ sleep disturbance _____ depression
_____ appetite disturbance _____ obsessive thoughts
_____ anxiety reactions _____ compulsive behaviors
_____ panic attacks _____ increased use of alcohol
_____ memory difficulties _____ increased use of recreational drugs
_____ hallucinations or unusual _____ personality changes (noted by self or
behavior (noted by others) others)
Please describe any of the above items:
3. Have you ever seen a mental health professional such as psychiatrist, psychologist or
counselor? ___ Yes _____No
If so, please include when, why, and duration of treatment.
4. Are you presently taking any form of psychiatric medication? ____Yes ____No
If so, please list names and dosages:
5. Are there any other concerns you have (about your current situation) that the treatment
team should be aware of?
8631 West Third Street, Suite 800-E Los Angeles, CA 90048
Office (310) 423-7900 Fax (310) 423-0777 E-mail csnsi.edu www.csmc.edu/nsi
Driving Directions/Parking Information
Extension 32100 to 76500
Driving Directions to CSMC Medical Towers
8631 West Third St. Suite 800-E Los Angeles, CA 90048
San Fernando Valley or Ventura County
Take the 101 South to the 405 South to the 10 East, exit on Robertson Blvd., ( North) to 3
rd
street
make a right to Sherbourne make a left and parking lot 4 is on your right hand side.
LAX, Beach Cities or Orange County
Take the 405 North to the 10 East, exit on Robertson Blvd., (North) to 3
rd
street make a right to
Sherbourne make a left and parking lot 4 is on your right hand side.
Pasadena, Duarte or Cities near the 134 and 210 Freeways
Take the 110 South to the 10 West , exit on Robertson Blvd., (North) to 3
rd
street make a right to
Sherbourne make a left and parking lot 4 is on your right hand side.
Monterey Park, El Monte, Baldwin Park or Cities near the 10 and 60 Freeways
Take the 10 west, exit on Robertson Blvd., (North) to 3
rd
street make a right to Sherbourne make a left
and parking lot 4 is on your right hand side.
From Westwood, Sherman Oaks or Van Nuys
Take the 405 South to the 10 East, exit Robertson Blvd., (North) to 3
rd
street make a right to
Sherbourne make a left and parking lot 4 is on your right hand side.
YOU WILL RECEIVE A LONG BLUE TICKET, WHICH IS AN INDICATION THAT YOU
ARE IN THE CORRECT PARKING STRUCTURE. YOU MAY ALSO PARK IN LOT 7
WHICH IS AN OPEN LOT NEXT TO PARKING LOT 4.
PLEASE REMEMBER TO BRING YOUR FILMS, HEALTH INSURANCE CARD AND
PHOTO IDENTIFICATION CARD WITH YOU TO YOUR APPOINTMENT.