New Patient Contact Form - Diamond Headache Clinic

Scheduling Preference

Appointment Day Preference*

Monday
Tuesday
Wednesday
Thursday
Friday

Appointment Time Preference

9:00–11:00 A.M.
1:00–3:00 P.M.

Appointment Location Preference*

Chicago, Illinois
Glenview, Illinois
Greenfield, Wisconsin

Follow this link for appointment request in the WI office: https://www.drtracipurath.com/schedule-appointment

Patient's Personal Information

Name*

First Last

Date of Birth*

Sex*

Male
Female
Other

Specify

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone*

Cell Phone*

Email*

Preferred Language*

Marital Status*

Patient Ethnicity*

Patient Race*

Employment Status*

Emergency Contact

Name*

First Last

Relationship*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Phone Number*

Please confirm the emergency contact phone number is different than the primary patient contact. If the number is the same, an emergency contact will not be added.

Guarantor Information

Name

First Last

Date of Birth*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Relationship to patient*

Primary Phone Number*

Primary Insurance Information

Insurance Cards must be presented at check-in.

Name of Insurance Company*

Insurance Type*

Note: We do not contract with any form of HMO or Medicaid. Patients with this type of insurance are considered self pay.

Primary Insurance Subscriber*

First Last

Relation to Patient*

Self
Spouse
Parent
Other

Subscriber Date of Birth*

Insured ID #*

Group #*

Eff. Date*

Insurance Phone Number*

Usually found on the back of the insurance card

Secondary Insurance Information

If applicable

Name of Insurance

Insurance Type

Name of Insured

First Last

Relation to Patient

Self
Spouse
Parent
Other

Insured Date of Birth

Insured ID #

Group #

Eff. Date

Insurance Phone Number

Usually found on the back of the insurance card

Referral Source

How did you hear about the Diamond Headache Clinic?

Referral Source*

Referring Physician*

First Last

Referring Physician Practice Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Referring Physician Phone Number

Patient Headache History Initial Intake

In the last year, have you ever been hospitalized for headaches?*

Yes
No

In the last six months, have you gone to the emergency room for headache treatment?*

Yes
No

At least once a week, do you miss school, work or social activities due to your headaches?*

Yes
No

Are you taking five or more medications for your headache?*

Yes
No

For over six months, have you been taking medications daily to abort your headaches?*

Yes
No

Have you seen more than two physicians for your headaches?*

Yes
No

Do you have headaches more than 15 days each month?*

Yes
No

In the past year, have you had an abnormal result for MRI of the head?*

Yes
No

Have you been diagnosed as Bipolar or Borderline?*

Yes
No