865NorthernBoulevard,GreatNeck,NY11021 Phone:5165704400 Fax:5165704444

INSTRUCTIONS: PLEASEFILLOUTENTIREQUESTIONNAIREANDRETURNTOTHECHIARIINSTITUTEWITHACOPYOF
YOURINSURANCECARDSVIAMAIL,FAXTO5165704444,OREMAILTO TCI@NSHS.EDU.
PatientName: _____________________________________________

Home#: ___________________________________

DateofBirth:______________________________ Age: __________

Work#: ___________________________________

SSN: _____________________________________________________

Cell#: ____________________________________

Occupation:_______________________________________________

Email:____________________________________

Address:___________________________________________________________________________________________________
EmergencyContact:____________________________Relationship: __________________ Phone#:____________________
PCP:_____________________________________________________

Neurologist: _______________________________

Phone:___________________________________________________

Phone: ____________________________________

Address: _________________________________________________

Address: __________________________________

__________________________________________________________

___________________________________________

__________________________________________________________

___________________________________________

Diagnosis:_________________________________________________________________________________________________
Primary Insurance: __________________________________________________________________________________
Member Name: ____________________________ Member ID: _______________________ DOB: _____________
Members SS#: _____________________________ Members Employer: _________________________________
Plan name: ________________________________ Effective Date: _______________________________________
Phone number on the back of the card:
________________________________________________________
Type of Policy (PLEASE CIRCLE ONE): HMO / PPO / AID / POS / INDEM / Out-of-state AID /
Commercial
What is the patients co-pay to see a specialist?
$__________
Does the patient have out of network benefits?
YES NO
If yes, what are pts out-of-network costs?
$__________ deductible $__________ maximum out-of-pocket
Patient is responsible for __________ % of charges
Is a referral needed for office consultation?
YES NO
(if patient is using out-of-network benefits, no referral is necessary)
NOTES:
YOUMUSTASKYOURINSURANCECARRIERWHETHERORNOTYOUWILLBEUTILIZINGTHEIROUTOFNETWORKBENEFITSFORTHEHOSPITALCHARGES
(RADIOLOGICWORKUPorINPATIENTSTAY).IFTHISISSO,YOURINSURANCECOMPANYMAYHOLDYOURESPONSIBLEFORCOINSURANCEANDDEDUCTIBLES.
PATIENTSSHOULDBEADVISEDTOINSISTTHATTHESESERVICESBECOVEREDATANINNETWORKRATE.

** PLEASE INCLUDE A COPY OF ALL INSURANCE CARDS WITH QUESTIONNAIRE **

Secondary Insurance: __________________________________________________________________________________
Member Name: ____________________________ Member ID: _______________________ DOB: _____________
Members SS#: _____________________________ Members Employer: _________________________________
Plan name: ________________________________ Effective Date: _______________________________________
Phone number on the back of the card:
________________________________________________________
Type of Policy (PLEASE CIRCLE ONE): HMO / PPO / AID / POS / INDEM / Out-of-state AID /
Commercial
Is a referral needed for office consultation?
YES NO
Hasthepatienthadpriorneurosurgery? YES NO When:_________________ Neurosurgeon:_______________________
PatientHt_______ Wt_______ Willthepatientneedsedationwithtesting? YES NO Isthepatientpregnant? YES NO

Visitusathttps://www.chiariinstitute.com

Name: ________________________
DOB: ________________________
Date: ________________________

Page2

TheChiariInstituteSymptomQuestionnaire

Selfreportofsymptoms: pleasecheckanysymptomsyou
havehadasaresultofyourdisease.
Headaches
Doyouhavepain/pressureatthebaseof
yourhead?
Doesyourpainradiatebehindyoureyes?
Doesyourpainradiatetoyourneckor
shoulders?
Isitworsenedbycoughing/sneezing/bowel
movements?
Doyouhavegeneralneckpain/stiffness?
Women:Isyourheadacheworsenedby
menses?
OcularDisturbances
Doyouhavepainorpressurebehindyour
eyes?
Areyousensitivetolight?
Doyouhaveblurredvision?
Doyouhavedoublevision?
Areyoumissingaportionofyourvisual
fieldwhenlookingstraightahead(Field
Cuts)?
OtoneurologicDisturbances
Doyouhavepressureinyourears?
Doyouhavedizzinesswithposition
changes?
Doyouhavefeelingsofunsteadinesswhen
standing?
Doyouhavefeelingsofunsteadinesswhen
walking?
Doyouhavehighpitchedringinginyour
ears?
Doyouhavetremors?
Doyouhavedecreasedhearing?
Doyouhaveverysensitivehearing?
Doyouhavevertigo(feelingsthatyouor
theroomarespinning)?
CranialNerve/BrainStemSymptoms
Doyouhavedifficultyswallowing?
Doyouhavethroattightness?
Doyouhavedifficultyspeaking?
Isyourvoicechanging,becominghoarse?
Doyouhavesleepapnea?
Doyousnore?
Haveyoueverpassedout?
Doyouhavepalpitations?
Doyoueverhaveshortnessofbreath?
Doyouhavefrequentnausea?

Yes

No

ExtracranialDisturbances
Yes
Doyousufferfromprickling,tinglingor
numbnessofyourextremities?
Doyouhaveincreasedsensitivitytopainor
touch?
Doyouhavediminishedsensitivitytopain?
Doyouhavepartialorcompletelossof
sensationinyourextremities?
Doyouhaveanabnormalburningpainin
yourextremities?
Doyouhavepainordecreasedsensation
overaspecificportionofyourextremities?
Doyouhaveanynoticeableskinchanges?
Ifyoucloseyoureyes,doyouhave
difficultydeterminingyourfootpositioning?
Doyouhaveweaknessofyourextremities?
Doyouhavelossofmuscletone?
Doyouhavedifficultypickingupsmall
objectswithyourfingers?
Doyouhavestiffnessofyourarmsorlegs?
BladderFunction
Doyouhavetheurge tourinate?
Doyouhavedifficultyinitiatingyoururine
stream?
Doyouhavedifficultycontrollingyoururine
(incontinence)?
OTHER:
BowelFunction
Doyouhaveconstipation?
Doyousufferfromdiarrhea?
Doyouhavedifficultycontrollingyour
bowels?
OTHER:
SexualFunction
Doyouhavedecreasedinterestinsexual
relations?
Doyouhavedifficultymaintainingarousal?
Doyouhavedifficultyobtainingorgasm?
Doyouhavedecreasedsensationinyour
pelvicarea?
Other:
SystemicSymptoms
Doyousufferfromchronicfatigue?
Doyousufferfromshorttermmemory
loss?
Doyousufferfromlongtermmemoryloss?
Doyousufferfromdepression?
Doyousufferfromirritability?
Doyouhavenippledischarge?
Doyouhavejointhypermobility?
Doyouhavewoundhealingproblems
Women:Doyouhaveirregularperiods?

Copyright(c)2002NorthShoreLongIslandJewishHealthSystem,Inc.Allrightsreserved.

No

Name: ________________________
DOB: ________________________
Date: ________________________
TheChiariInstituteSymptomQuestionnaire
Pleasecompletethefollowinginformationaboutrecent
testsandconsultations.
NeurologicTests
MRIBrain
CineMRI(CSFflow
study)
MRICervicalSpine
MRIThoracicSpine
MRILumbarSpine
CTHead
CTCervicalSpine
CTThoracicSpine
CTLumbarSpine
CTMyelogram
XraySkull
Xrayshuntseries
XrayCervicalSpine
XrayThoracicSpine
XrayLumbarSpine
PETScan:Brain
LumbarPuncture
StellateGanglion
Block
Other:

Yes

No

Date
(Month/Year)

MiscellaneousTests

Yes

No

Date
(Month/Year)

Laboratory
PituitaryHormone
Profile
LymeTiter
RheumatologyPanel
Other:

xxx

xxx

xxxxxxxxxxxxx

Consultations
PainManagement
Neurology
Neuropsychology
Cardiology
Rheumatology
Allergist
ENT/Otolaryngology
Other:

xxx

xxx

xxxxxxxxxxxxx

VestibularFunction
Testing
TiltTable
HolterMonitor
BariumSwallow
SleepApnea
Monitoring
SleepEEGMonitoring
PulmonaryFunction
Tests
Other:

Your
KarnofskyScale:Pleasecheckthestatementthatbest
describesyourcurrentleveloffunctioning.Pleasechoose
Answer
onlyone.
Ifeelnormal:Nocomplaints,noevidenceofdisease.
Iamabletocarryonnormalactivitywithminorsymptoms.
Icarryonnormalactivitywitheffortandsomesymptoms.
Iamabletocareformyself,butunabletocarryonnormal
activities.
Irequireoccasionalassistancebutcancareformostofmyneeds.
Irequireconsiderableassistanceandfrequentcarebyothers.
Iamdisabled.Irequireconsiderableassistanceandfrequent
carebyothers.
Iamseverelydisabled.Iamhospitalized,butdeathisnot
imminent
Iamverysick.Irequireactivesupportivecarebyothers.
Ihavefatalprocessesthatarerapidlyprogressing.Iamnear
death

Score(Foroffice
use)
100
90
80
70
60
50
40
30
20
10

Copyright(c)2002NorthShoreLongIslandJewishHealthSystem,Inc.Allrightsreserved.

Page3

Name: ________________________
DOB: ________________________
Date: ________________________

Page4

TheChiariInstituteSymptomQuestionnaire
PastMedicalHistory
Diabetes
Cancer
Hypertension
Stroke/TIA
CoronaryArteryDisease
MitralValveProlapse
LymeDisease
Thyroiddisease
Asthma
COPD
Glaucoma
VisualImpairment/LegallyBlind
HearingDeficit/Usehearingaid
Paraplegia/Quadriplegia
Other:

Yes No

PastSurgicalHistory

Yes

No

Date/s
Performed

SpineDisturbances

Yes

No

Comment:

Lowerbackpain?
Legpainingeneral?
TraumaticHistory

Yes

No

Date/s

CardiacBypass/Stent
Pacemaker
Defibrillator
ProstheticImplantation
ValveReplacement
CataractRemoval
Other:

Headinjury?
Whiplashinjury?
Fallonheadorneck?

PastNeurosurgicalHistory: Pleaselistinreversechronologicalorder,startingwiththemostrecentsurgery
DATE(MONTH/YEAR)

PROCEDURE

SocialHistory
Doyouusetobacco?
Ifyes,areyouinterestedinsmokingcessation
materials?
Ifyouare18yearsoldoryounger,doesyourhome
environmentexposeyoutosecondhandsmoke?
Doyouusealcohol?
Doyouuseintravenousdrugs?
Doyouuseillegaldrugs?

Surgeon

Yes No

Hospital

Quit
#packsperday:______orwhendidyouquit:______

NA
#drinksperday:______#daysperweek:______

Copyright(c)2002NorthShoreLongIslandJewishHealthSystem,Inc.Allrightsreserved.

Name: ________________________
DOB: ________________________
Date: ________________________
TheChiariInstituteSymptomQuestionnaire
Pleaseincludeallprescription,overthecounter,herbalandalternativetherapiesinyourmedications.
MedicationName

Dose

Allergies(includemedications,
foods,andmaterials)
Latex

Frequency(numberoftimesperday)

Yes

No

Route(oral/injection)

Reaction(i.e.:anaphylaxis,rash,itching,swelling)

Antibiotics
Name/s:
Medication
Name(s):
Food
PlasticTape
Acrylic:(i.e.productsfromnailsalons)
Other:

TestingHistory
Areyouclaustrophobic?
Doyourequiresedationfortesting?

Yes

No

Copyright(c)2002NorthShoreLongIslandJewishHealthSystem,Inc.Allrightsreserved.

Page5