print a new patient packet - Banner Alzheimer's Institute

901 E. Willetta Street
Phoenix, Arizona 85006
(602) 839-6900
www.banneralz.org
Welcome to the Banner Alzheimer’s Institute Memory Disorders Clinic, a Center of Excellence for Banner Health.
We look forward to providing you with a new standard of care. Our Memory Disorders Clinic provides
comprehensive care utilizing a team of physicians, physician assistants, nurses, social workers and psychologists.
We strive to bring the best in diagnosis, treatment, research options, and support in order to live a healthy and
productive life, whether you are the patient or family.
Enclosed you will find paperwork that you must review, sign, and return. All the forms that require a signature
must be returned prior to scheduling an appointment. It is important that this paperwork be completed in its
entirety to avoid a delay in scheduling your appointment.
Below are the forms that must be signed and returned to our office prior to setting up an appointment.
New Patient Questionnaire
Authorization to Use or Disclose Protected Health Information (medical records release)
You may fax forms to 602-839-6906
OR
Scan and email forms to BAIinfo@bannerhealth.com
The following are guidelines for your first appointment in our Memory Disorders Clinic:
* Please come with a patient advocate. (e.g. family member or friend).
* Please arrive 15 minutes prior to the scheduled visit.
* Please bring all medical insurance cards.
* Please bring Healthcare and Mental Healthcare Power of Attorney documentation (if applicable).
* Please bring two forms of patient identification.
* Prepare to pay a co-pay (if required) at the time of appointment.
Please contact us at 602-839-6900 with any questions you may have. We look forward to meeting with you!
Sincerely,
The Memory Disorders Clinic Team

NEW PATIENT QUESTIONNAIRE
PATIENT INFORMATION
NAME (LAST, FIRST, MIDDLE)
DATE:
DATE OF BIRTH (REQUIRED)
ADDRESS CITY STATE ZIP CODE
HOME PHONE CELL PHONE SSN#
EMAIL ADDRESS
RELATIONSHIP STATUS
PRIMARY LANGUAGE
GENDER
ETHNIC BACKGROUND:
HISPANIC CAUCASIAN AFRICAN AMERICAN NATIVE AMERICAN ASIAN OTHER:
PERSON COMPLETING QUESTIONNAIRE (IF DIFFERENT THAN ABOVE)
NAME (LAST, FIRST, MIDDLE)
RELATIONSHIP TO PATIENT
ADDRESS CITY STATE ZIP CODE
HOME PHONE CELL PHONE EMAIL ADDRESS
YES NO DOES THE PATIENT HAVE A DURABLE HEALTH CARE POWER OF ATTORNEY
YES NO DOES THE PATIENT HAVE A DURABLE MENTAL HEALTH POWER OF ATTORNEY
IF YES, PLEASE BRING SUPPLY A COPY OF SUPPORTING DOCUMENTS TO INITIAL VISIT.
YES NO CAN WE CONTACT YOU TO SET UP THE NEW PATIENT APPOINTMENT
IF NO, WHO SHOULD WE CONTACT
PHONE NUMBER
REFERRAL INFORMATION
WHO REFERRED YOU TO THE MEMORY CLINIC
YES NO HAS THE PATIENT HAD A CONSULTATION AND WORK-UP FOR CURRENT SYMPTOMS
IF YES, PLEASE PROVIDE:
PHYSICIAN NAME DATE SEEN PHONE NUMBER
YES NO DOES THE PATIENT HAVE A PRIMARY CARE PHYSICIAN
IF YES, PLEASE PROVIDE:
PHYSICIAN NAME
PHONE NUMBER
Page 1 of 6

CURRENT PROBLEM
WHAT IS THE MAIN REASON FOR THE PATIENT’S VISIT TO THE CLINIC
YES NO IS THE PATIENT MORE FORGETFUL
YES NO DOES THE PATIENT REPEAT HIMSELF/HERSELF
YES NO DOES THE PATIENT NEED REMINDERS
YES NO DOES THE PATIENT FORGET APPOINTMENTS OR EVENTS
YES NO
DOES THE PATIENT HAVE TROUBLE WITH CALCUALTIONS/MANAGING FINANCES
(i.e. balancing a checkbook)
YES NO
DOES THE PATIENT NEED HELP WITH PERSONAL CARE
(i.e. eating, dressing, bathing or using the bathroom)
YES NO DOES THE PATIENT HAVE TROUBLE FINDING WORDS OR FINISHING SENTENCES
YES NO HAS THE PATIENT LOST INTEREST IN HIS/HER USUAL ACTIVITIES
YES NO IS THE PATIENT SAD OR TEARFUL
YES NO IS THE PATIENT IRRITABLE OR AGITATED
WHEN WAS THE PROBLEM FIRST OBSERVED
WHICH BEST DESCRIBES THE ONSET OF THE PROBLEM SUDDEN ONSET GRADUAL ONSET
HOW HAS THE PROBLEM PROGRESSED OVER TIME STEP-WIDE PROGRESSION GRADUAL PROGRESSION
WHAT MAKES PROBLEMS WORSE
WHAT MAKES PROBLEMS BETTER
MEDICAL HISTORY
PLEASE LIST ANY BIRTH INJURIES OR ILLNESSES:
PLEASE LIST ANY CHILDHOOD AND ADOLESCENT INJURIES OR ILLNESSES:
YES NO HAS THE PATIENT HAD A BRAIN SCAN IF YES, LOCATION: DATE:
YES NO HAS THE PATIENT HAD A STROKE IF YES, DATE(S):
PLEASE LIST PAST AND CURRENT MEDICAL, NEUROLOGICAL AND PSYCHIATRIC PROBLEMS
PROBLEM DIAGNOSIS DATE ACTIVE
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
SURGICAL/HOSPITALIZATION HISTORY
REASON FOR HOSPITALIZATION HOSPITAL DATE
Page 2 of 6

MEDICATION HISTORY
ALLERGIES
PLEASE LIST ALLERGIES TO MEDICATIONS:
PLEASE LIST ALLERGIES TO FOODS:
PLEASE LIST OTHER ALLERGIES:
PLEASE LIST ALL MEDICATIONS TAKEN WITHIN THE LAST MONTH:
PRESCRIPTION MEDICATIONS
DRUG NAME
DOSE
TIMES
PER DAY
DATE
STARTED
DATE
STOPPED
MEDICAL CONDITION
BEING TREATED
OVER THE COUNTER MEDICATIONS
DRUG NAME
DOSE
TIMES
PER DAY
DATE
STARTED
DATE
STOPPED
MEDICAL CONDITION
BEING TREATED
VITAMINS
DRUG NAME
DOSE
TIMES
PER DAY
DATE
STARTED
DATE
STOPPED
MEDICAL CONDITION
BEING TREATED
Page 3 of 6

SOCIAL HISTORY
YEARS OF EDUCATION PREVIOUS OR CURRENT OCCUPATION YEARS IN OCCUPATION
CURRENT LIVING SITUATION:
ALONE IN HOME/ APT WITH SPOUSE/ FAMILY/ FRIEND ASSISTED LIVING NURSING HOME OTHER
SUBSTANCE USE HISTORY
ALCOHOL USE
YES NO HAS THE PATIENT EVER USED ALCOHOL EXCESSIVELY
CURRENT USE: HOW MANY DRINKS PER WEEK
PAST USE: HOW MANY DRINKS PER WEEK
TOBACCO USE
YES NO DOES THE PATIENT CURRENTLY SMOKE IF NO, DATE OF CESSATION:
IF PATIENT EVER SMOKED: # OF PACKS PER DAY: # OF YEARS SMOKED:
SUBSTANCE USE
YES NO HAS THE PATIENT EVER MISUSED LEGAL OR ILLEGAL SUBSTANCES
IF YES: TYPE: DURATION:
FAMILY HISTORY
DOES THE PATIENT HAVE A BLOOD RELATIVE WITH SYMPTOMS OF OR DIAGNOSIS OF:
YES NO DEMENTIA/SENILITY/ALZHEIMER’S IF YES, RELATIONSHIP:
YES NO PARKINSON’S IF YES, RELATIONSHIP:
YES NO STROKES IF YES, RELATIONSHIP:
YES NO PSYCHIATRIC/MENTAL ILLNESS IF YES, RELATIONSHIP:
YES NO MENTAL RETARDATION IF YES, RELATIONSHIP:
YES NO DOES THE PATIENT HAVE LIVING SIBLINGS WITHOUT DEMENTIA
PLEASE LIST DISEASES/ILLNESSES IN THE IMMEDIATE FAMILY:
Page 4 of 6

MEDICAL HISTORY (cont)
PLEASE INDICATE IF THE FOLLOWING ISSUES ARE A PROBLEM.
IF YES, PLEASE DESCRIBE IN THE COMMENT BOX.
GENERAL
SKIN
EYES/EARS
NOSE/THROAT
CARDIOVASCULAR
RESPRITORY
GASTROINTESTINAL
GENITOURINARY
ENDOCRINE
HEMATOLOGICAL
MUSCULOSKELETAL
PSYCHIATRIC
NEUROLOGICAL
OTHER
NO YES
WEIGHT
APPETITE
SLEEP
ENERGY LEVEL
SEXUAL DRIVE/FUNCTION
RASH
VISION
HEARING
TASTE/SMELL
SPEECH
SWALLOWING
HIGH BLOOD PRESSURE
CHEST PAIN
PALPITATIONS
LIGHT-HEADEDNESS
BREATHING
BOWEL MOVEMENTS
DIGESTION
URINATION
THYROID
BLOOD SUGAR
ANEMIA
BLEEDING/BRUISING/CLOTTING
JOINT PAIN/SWELLING
POSTURE
MOOD/MOTIVATION
HALLUCINATIONS
AGRESSION
IRRITABILITY
HEADACHE
DIZZINESS
ALERTNESS
TREMOR
LIMB WEAKNESS
NUMBNESS/TINGLING
BALANCE
OTHER
COMMENTS
Entire packet reviewed by: Date: _
Page 5 of 6

HEALTH INSURANCE
PLEASE COMPLETE THIS SECTION IN ITS ENTIRETY. MISSING INFORMATION WILL DELAY PROCESSING.
PRIMARY INSURANCE
INSURANCE NAME
MEMBER ID#
INSURANCE CLAIMS ADDRESS GROUP #
POLICY HOLDER NAME
RELATIONSHIP TO POLICY HOLDER SELF SPOUSE/PARTNER DEPENDANT
INSURANCE PHONE (EACH CAN BE FOUND ON INSURANCE CARD)
MEMBER’S INSURANCE TOLL FREE PHONE NUMBER:
INSURANCE NOTIFICATION/PROVIDER’S TOLL FREE PHONE :
SECONDARY INSURANCE
INSURANCE NAME
MEMBER ID#
INSURANCE CLAIMS ADDRESS GROUP #
POLICY HOLDER NAME
RELATIONSHIP TO POLICY HOLDER SELF SPOUSE/PARTNER DEPENDANT
INSURANCE PHONE (EACH CAN BE FOUND ON INSURANCE CARD)
MEMBER’S INSURANCE TOLL FREE PHONE NUMBER:
INSURANCE NOTIFICATION/PROVIDER’S TOLL FREE PHONE NUMBER:
PHARMACY INFORMATION
PHARMACY NAME
PHARMACY PHONE
PHARMACY ADDRESS
IF MAIL ORDER, PLEASE PROVIDE ID#
FOR OFFICE USE ONLY
Page 6 of 6

Patient Label
AUTHORIZATION TO USE OR DISCLOSE
PROTECTED HEALTH INFORMATION
I authorize ________________________________________________ to disclose the following information from the health record of:
PATIENT
INFORMATION
Patient Name Date of Birth MR#
Address
Phone Number
City State Zip
Dates of Service: From ___________________________________________ To ____________________________________________
INFORMATION
REQUESTED
PURPOSE
❑
All Pertinent Records
(includes those listed below)
❑ Consultation
❑ Discharge Summary
❑ ER Report
❑ EKG Report
❑ History & Physical
❑ Laboratory
❑ Operative Report
❑ Pathology Report
❑ X-Ray Reports
❑ Assessment(s)
❑ X-ray Image(s) ________________________
❑ Billing Record
❑ Photos
❑ Behavioral Health/Psychiatric Care Record
❑ Screening and/or Treatment of Alcohol
and/or Substance Abuse
❑ Entire Official Patient Medical Record
❑ Specify: ______________________________
Home Care/Hospice Records
❑ Clinical Assessment(s)
❑ Clinical Evaluation(s)
❑ Continuation Orders
❑ Plan of Care
❑ Visit Notes
❑ Itemized Billing Statement
❑ Specify:_________________________
____________________________________
❑ Self ❑ Continuing Medical Care
❑ Other (specify reason)_________________________________________________________________________________________
INFORMATION
TO BE GIVEN
TO
Company, Person, Facility
Phone Number
Address City State Zip Code
I understand that information in my health record may include information relating to Sexually Transmitted Disease, Acquired
Immunodeficiency Syndrome (AIDS), Human Immunodeficiency Virus (HIV) and other communicable diseases, Behavioral Health
Care/Psychiatric Care, and treatment of alcohol and/or drug abuse; my signature authorizes release of any such information.
I may refuse to sign this authorization form. I understand that Banner Health will not condition or deny treatment on my signing this
authorization.
I understand that I may revoke this authorization at any time, except to the extent that action based on this authorization has already been
taken. Banner Health's Notice of Privacy Practices explains the process for revocation, which includes a request in writing.
Unless I revoke this authorization earlier, it will expire 6 months from the date signed or as specified: _____________________ .
I understand that, if this information is disclosed to a third party, the information may no longer be protected by state, federal regulations
and may be re-disclosed by the person or organization that receives the information.
I release Banner Health, its employees and agents, medical staff members, and business associates from any legal responsibility or
liability for the disclosure of the above information to the extent indicated and authorized herein.
Signature of Patient
Date
In requesting the medical records as the designated agent, in signing below, I attest to the continuing inability of the above patient to make or
communicate health care decisions.
Signature of Legal Representative
For Healthcare Use Only
Relationship to Patient or
Description of Authority to Act for Patient
Employee completed/reviewed form with patient: ______________________________________________ ID verified:_____________
Date Received: _______________________ Date Sent: ______________________ Processor: _________________________________
Records Picked Up By: _________________________________ Date: ______________
*1200* HIMS/ROI
1200
(09/2009)