ORANGE PARK NEUROSURGERY P.L.
                                            MARK A. SPATOLA, M.D.
         BRING MRI, CT OR X-RAY FILMS OR CD TO OFFICE VISIT

    TODAY'S DATE____________________________

    NAME:____________________________________________________________
                LAST                                                 FIRST                                       M.I.
         GENDER:   (CIIRCLE ONE PLEASE)                           MALE                   FEMALE

HOME PH:  
(      )                                        CELL PH: (       )                                      

WORK PH: (      )                                         OTHER:  (        )                                      

HOME ADDRESS:                                                                                                       

CITY:                                          STATE:                                ZIP:                               

SOC. SEC. #:                                                  DATE OF BIRTH:                                 
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PRIIMARY DR.
                                        REFERRING DR.                                         

PHARMACY:                                            ADDRESS:                                                  

PH. PHONE                                             PHARMACY FAX                                          
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MARITAL STATUS:  (CIRCLE ONE)   MARRIED    DIVORCED    SINGLE   WIDOWED

SPOUSE'S NAME:
                                                                                                       

SPOUSE'S SOC. SEC.#:                                      DATE OF BIRTH:                             

EMERGENCY CONTACT:                                                                                            

PH. NUMBER:                                             RELATIONSHIP:                                        
**********************************************************************************************************
EMPLOYMENT INFORMATION: (CIRCLE ONE PLEASE)
EMPLOYED     RETIRED     DISABLED     STUDENT     NOT EMPLOYED

EMPLOYER:
                                     ADDRESS:                                                         

CITY:                                                STATE:                      ZIP:                                   
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IS YOUR APPOINTMENT RELATED TO AN ACCIDENT? (CIRCLE ONE)    YES     NO

IF YES:  (CIRCLE ONE)                        AUTO                WORKERS COMP

OTHER:
                                      DATE OF ACCIDENT:                                               

IS THERE PENDING LITIGATION?    (CIRCLE ONE)      YES           NO

ATTORNEY'S NAME:
                                                   PHONE:                                    




________________________________________
Print Name

ACKNOWLEDGMENT OF RECEIPT

I have reviewed a copy of the Privacy Statement, for Orange Park Neurosurgery P.L. at         
2021 Kingsley Avenue, Suite 101, Orange Park, Florida 32073

________________________________       _____________________________
Signature of Patient                                                       Date

INSURANCE INFORMATION

Insurance Name ___________________________________________________

Policy Number_______________________Group Number__________________

Address__________________________________________________________

Person Insured__________________Date of birth_________SSN____________

Second Insurance
Insurance Name___________________________________________________

Policy Number_____________________Group Number____________________

Address__________________________________________________________

Person Insured__________________Date of birth_________SSN____________

INSURANCE AUTHORIZATION AND ASSIGNMENT

I authorize payment of medical benefits for any services to me by any providers affiliated with
Orange Park Neurosurgery, to be paid directly to Orange Park Neurosurgery and authorize
release of any medical information necessary to process this claim and request payment for
their services.  I understand that I am responsible for any amount not covered by my insurance
of all allowed charges. I understand that I am responsible for my co-pay before seeing the
doctors. I direct my insurance carrier that a photocopy of the authorization shall be considered a
valid assignment of benefits in lieu of the original.  This release shall also serve as authorization
to collect from the insurance company or cover any appeals necessary for said collection. It is
mandatory that you tell our office if you know that another party is responsible for paying for
your treatment.  Section 1128B of the Social Security Act and 31 USC 3801-3812 provide
penalties for withholding this information.

Patient's Signature_______________________________Date______________________



                             MEDICAL RECORDS RELEASE

    I hereby authorize _____________________________________________________
    to release medical records pertaining to my examination, treatment, and prognosis to:



                                      Mark A. Spatola, M.D.
                             Orange Park Neurosurgery, P.L.
                            2021 Kingsley Avenue, Suite 101
                                     Orange Park, FL 32073
                              Phone Number (904) 276-3376
                                Fax Number (904) 276-5308

    A photocopy of this authorization shall be considered a valid release in lieu of the original
    Patient Name (print)_____________________________________________________

    Patient Signature_________________________________________________________

    Date of Birth_____________________________________________________________

    Social Security Number_____________________________________________________






Orange Park Neurosurgery, P. L.
Dr. Mark Spatola

Name:
_____________________________  Date:  _________________________

Age:             ___________                        Referring Physician: _______________
Height:         ___________                        Primary Physician: ________________
Weight:        ___________

Chief Complaint (Reason for visit): ______________________________________

__________________________________________________________________

Medical History: (Check all that apply for self (s), mother (M), father (F)

S  M  F                                            S  M  F                               S  M  F
( ) ( ) ( ) High Blood Pressure       ( ) ( ) ( ) Liver Disease         ( ) ( ) ( ) Phlebitis/Blood Clots
( ) ( ) ( ) Heart Disease                 ( ) ( ) ( ) Kidney Disease      ( ) ( ) ( ) Bleeding Disorder
( ) ( ) ( ) Heart Attack                    ( ) ( ) ( ) Thyroid Disease     ( ) ( ) ( ) Asthma
( ) ( ) ( ) Irregular Heart rhythm     ( ) ( ) ( ) Diabetes                ( ) ( ) ( ) Emphysema/COPD
( ) ( ) ( ) Stroke                             ( ) ( ) ( ) Osteoporosis         ( ) ( ) ( ) Cancer (Type:____)
( ) ( ) ( ) Rheumatoid Arthritis       ( ) ( ) ( ) Seizure                   ( ) ( ) ( ) Trauma
( ) ( ) ( ) Glaucoma                       ( ) ( ) ( ) Osteo-Arthritis        ( ) ( ) ( ) Sleep Apnea
( ) ( ) ( ) Depression/Anxiety         ( ) ( ) ( ) Fibromyalgia          ( ) ( ) ( ) Other:_________
( ) ( ) ( ) High Cholesterol             ( ) ( ) ( ) GERD                     ( ) ( ) ( ) Other: ________

Surgical History:                 ( ) Check here if none

Low Back Surgery:  (when)  _______ (where) ____________  (Surgeon)____________
Neck Surgery:         (when)  _______(where) _____________ (Surgeon)____________
Heart Surgery:        (when)  _______(where) _____________  (Surgeon)____________
Joint Replacement: (when)  _______(where) _____________  (Surgeon)____________
(which joint) _______________________
( ) Appendix
( ) Gallbladder
( ) Hernia
( ) Hysterectomy (total or partial)
( ) Other: ____________________
( ) Other: ____________________

Allergies: (Check all that apply and list reactions)

( ) Food: _________________      ( ) Penicillin:   ___________________
( ) Iodine:  _______________        ( ) Sulfa:         ___________________
( ) IV Dye: _______________        ( ) Other:        ___________________
( ) Latex: ________________        ( ) Other:        ___________________
( ) Adhesive tape: _________        ( ) Other:        ___________________



















_______________________________________
Print Name


Orange Park Neurosurgery, P. L.
Dr. Mark Spatola


Continued Patient Name: ________________________  Date: _____________


Medications: (List name/dose/ how often you take and over the counter (OTC)                              medicines)

Medicine Name                            Dose:                                        How often:
________________                  __________                          _______________
________________                  __________                          _______________
________________                  __________                          _______________
________________                  __________                          _______________
________________                  __________                          _______________
________________                  __________                          _______________
________________                  __________                          _______________
________________                  __________                          _______________
________________                  __________                          _______________

List any over the counter medications, herbals, diet pills or aspirin:                                                   
______________________________________________________________
______________________________________________________________


Social History:

Occupation: _________________  ( ) Full-time  ( ) Part-time        ( ) Disabled  ( ) Retired
( ) Married        ( ) Divorced        ( ) Single        ( ) Widowed (Year___________)
( ) Children # ______________
Education: ___________grade   ( ) High school  ( ) College  ( ) Post-graduate
Smoker:( ) Yes ( ) No # of Packs daily _____  How long (Years) ___ ( ) Year Quit ____  
Alcohol: ( ) None   ( ) Daily  ( ) Few per Week   ( ) One per week  ( ) Occasionally ( ) Rare
Illegal Drug Use:   ( ) Never        ( ) Other __________        
Ever been in Drug/Alcohol Treatment ( ) Yes ( ) No
Exercise: ( ) None ( ) Daily ( ) Few times per week  ( ) 1/week  ( ) 1/month   ( ) Other ____













____________________________________
Print Name


Orange Park Neurosurgery, P. L.
Dr. Mark Spatola


Continued        Patient Name: ________________________  Date: _____________

Review of Systems:

Possibly Pregnant: ( ) Yes        ( ) No                ( ) Right Handed        ( ) Left Handed

( ) None    General     ( ) Numbness/ Tingling      ( ) Local Weakness         ( ) Coordination
( ) Taste   ( ) Speech    ( ) Affect     ( ) New incontinence (urine/ Stool)

( ) None    Constitutional   ( ) Fever   ( ) Weight loss    ( ) Tiredness     ( ) Head Trauma  

( ) None    Eyes           ( ) Blurred Vision           ( ) Glaucoma               ( ) Double Vision

( ) None    Ears/ Nose/ Throat   ( ) Deafness  ( ) Ringing  ( ) Vertigo/Dizziness ( ) Smell  ( ) Swallowing

( ) None    Heart      ( ) Chest pain  ( ) Irregular heart rhythm ( ) High blood pressure ( ) Pounding in chest

( ) None    Lungs     ( ) Shortness of breath ( ) Wheezing  ( ) Cough ( ) Emphysema/COPD ( ) Cough up blood

( ) None    Abdomen    ( ) Diarrhea  ( ) Constipation  ( ) Black Stool  ( ) Heartburn   ( ) Stomach Bleeding

( ) None    Urinary       ( ) Burning    ( ) Loss of urine   ( ) Blood in urine ( ) Kidney disease

( ) None    Menstrual   ( ) Regular    ( ) Irregular    ( ) Severe Pain   ( ) Post Menopausal

( ) None    Musculoskeletal  ( ) Sprains ( ) Rheumatoid Arthritis ( ) Osteo-arthritis ( ) Swelling ( ) Stiffness

( ) None    Skin/Breast      ( ) Rash   ( ) Sores   ( ) Lumps   ( ) Masses   ( ) Cancer: _____

( ) None    Neurologic   ( ) Balance problems      ( ) Memory problems        ( ) falls  ( ) Neuro disease

( ) None    Behavioral    ( ) Depression    ( ) Anxiety     ( ) Sleep Disturbances     ( ) Hallucinations

( ) None    Endocrine    ( ) Thyroid disease ( ) Diabetes ( ) Adrenal disease  ( ) Sleep all time ( ) Hyperactive

( ) None    Blood/Lymphatic  ( ) Easy bruising   ( ) Bleeding Problems   ( ) Anemia   ( ) Sickle Cell

( ) None    Immunologic         ( ) Itching   ( ) Frequent Colds and Infections  ( ) HIV  ( ) Hepatitis ______   ( ) MRSA   


Reviewed:________________________Date: _____________________
Reviewed:________________________Date: _____________________
Reviewed:________________________Date: _____________________  



Patient Name_________________________ D/O/B___________________________




Government regulations  require that we report the race of all patients.

PLEASE CHECK ONE FOR EACH SECTION



(Please check one)                                (Please check one)

Race                                                           Ethnicity

___ Caucasian (White)                            ____ Not Hispanic/Latino    

___ African American (Black)                   ____ Hispanic/Latino

___American Indian                                  

___Alaska Native                                     

___Asian                                             

___Hispanic/Spanish/Latino                        

___Native Hawaiian/Pacific Islander          

___Portuguese                                             

___Creole                                                 

___Other________________                    




_________________________________        ________________________
Patient/Guardian Signature                                Date