Paperwork - Marshall Allyn White, MD

Full Name *

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Street Address

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Home Phone Number

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SexMaleFemale

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Marital StatusMarriedSingleDivorce

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Family Doctor

Dr. Phone Number

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If patient is a minor:

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ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES

Marshall Allyn White, MD reserves the right to modify the privacy practices outlined in this notice. We
are required by law to maintain the privacy of individuals with this notice of our legal duties and
privacy practice with respect to protected health information. Signature below is only an
acknowledgement that you have received a Notice of Privacy Practices.

Signature of patient

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Signature of Legal Guardian

Date

MEDICAL AUTHORIZATION

I authorize Marshall Allyn White, MD to release or receive from other healthcare providers any medical
information that may be necessary for medical care or in the processing of applications for financial
benefit. I understand the Health Insurance Portability and Accountability Act of 1996. I understand that
this authorization covers only information necessary to conduct, plan and direct treatment and follow up
and conduct normal healthcare operations

I further understand that payment in full is due at the time of service.

Signature of patient

Date

Signature of Legal Guardian

Date

(A PHOTOCOPY OF THIS AUTHORIZATION SHALL BE VALID AS THE ORIGINAL)

Marshall Allyn White, MD
1470 Ben Sawyer Blvd, Suite 8
Mt. Pleasant, SC 29464
Ph: (843) 696-3705
Fx: (843) 388-5839

MARSHALL ALLYN WHITE, MD

Board Certified Neurologist
Certified Brain Injury Specialist

Patient Name

Date

Chief Complaint (Reason for visit)

History of your present illness (Explain problem in detail)

Have you had testing or treatment for this problem? (MRI, CT, Labs, Etc.) Please list type of test or procedure with the date and facility.

Marshall Allyn White, MD

1470 Ben Sawyer Blvd, Suite 8
Mt. Pleasant, SC 29464
Ph: (843) 696-3705
Fx: (843) 388-5839

MARSHALL ALLYN WHITE, MD

Board Certified Neurologist
Certified Brain Injury Specialist

SOCIAL HISTORY

Do you drink alcohol?YesNo

Do you use tobacco?YesNo

Do you use any other recreational drugs?YesNo

If so, type? ____________ Occupational StatusFull TimePart TimeRetiredDisabled

What is/was your occupation?Option 1Option 2

Marshall Allyn White, MD

1470 Ben Sawyer Blvd, Suite 8
Mt. Pleasant, SC 29464
Ph: (843) 696-3705
Fx: (843) 388-5839

MARSHALL ALLYN WHITE, MD

Board Certified Neurologist
Certified Brain Injury Specialist

SURGICAL HISTORYPlease list any surgeries that you have had performed in the past.SURGERYDATE

Please list any allergies that you may have.1234

NOTES:

ASSESSMENT:

PLAN:Option 1Option 2

Marshall Allyn White, MD

1470 Ben Sawyer Blvd, Suite 8
Mt. Pleasant, SC 29464
Ph: (843) 696-3705
Fx: (843) 388-5839

MARSHALL ALLYN WHITE, MD

Board Certified Neurologist
Certified Brain Injury Specialist

HISTORY OF PRESENT ILLNESS

Cause of Pain:

Date pain began:

Description of pain:

Current Pain Rating:

Is the pain always the same?

Duration of pain:

Aggravating factors:

Previous treatments: __

Previous Diagnostic Studies: _

Previous Surgeries

Was surgery helpful

PAST TREATMENT

Have you treated in another pain management center?

Have you ever had psychiatric or psychological treatment?

Description:

Have you ever required treatment for substance abuse or alcohol use?

Description:

SLEEP DISTURBANCES

Do you have difficulty falling asleep?

Do you have difficulty maintaining sleep?

Are you awakened by pain?

Do you have difficulty staying awake during the day?

DEMOGRAPHIC DETAILS

College Degree?

Current Occupation?

Is pain result of a work-related injury?

Are you receiving compensation?

Are you represented by an attorney?

Marshall Allyn White, MD

1470 Ben Sawyer Blvd, Suite 8
Mt. Pleasant, SC 29464
Ph: (843) 696-3705
Fx: (843) 388-5839

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