POLICY REGARDING LEGAL CASES AND TESTIMONY JEFFERSON NEUROLOGY ASSOCIATES at The Jefferson Comprehensive Concussion Center 4050 South 26th Street, Suite 140 Philadelphia, PA 19112 Dear Patient: This statement is to acquaint you with our policy in regard to accepting cases with legal involvement requiring testimony. Because of our heavy clinical, research and teaching responsibilities and the ongoing requirements of good patient care, we find it impossible to accept any new patients with legal involvement where the case requires testimony. It is frequently impossible to predict which will not. It has been our decision to accept no cases of this nature and to refer patients to other physicians for their care. Our predominant reason for declining participation in any legal case requiring testimony is that it would ultimately mean that we would have to deny medical care to other patients. We feel that our primary obligation is to render medical care and treatment, rather than testimony and assistance in law suits. Your signature of this document states that you understand that any member of the Jefferson Neurology Department including physicians, midlevel providers, administrators, and support staff will treat you as a patient, but will not testify in court or do any type of testimony or depositions, nor will you or your attorney subpoena any member of the Neurology Department to provide any type of testimony or deposition. Date of Birth: Print Patient Name X Date: Signature of Patient
Neurology Concussion Intake Form Welcome to the Jefferson Comprehensive Concussion Center. In order for Dr. Serruya to provide you or your loved one with the most effective care, we ask that you fill out this health history form to the best of your ability. Patient s Name: Date: Name of the person filling out this form, if not the patient: Please provide your referring physician s contact information including NAME, CITY and STATE: Have you seen any other medical providers since your most recent concussion? Concussion History Did you suffer from headaches prior to your concussion? YES NO If yes, please explain. Have you ever had a concussion before? YES NO Please list the dates (approximate if needed) of your previous concussions. When was your most recent concussion? How did the concussion occur? What part of your head was hit? Was there a loss of consciousness? Did you have any seizures? Was alcohol involved? Have you been consuming alcohol since the concussion? Have your social habits changed? Are you having trouble in school or work? Have you been driving since the concussion? Do friends and family think that you are acting your usual self? Yes No N/A Comments
Medical History: If able, please answer the following: Yes No I Don t Know Were you the product of a normal pregnancy? Did you spend time in the neonatal intensive care unit? Did you hit major milestones at the same time as other children? Have you ever Yes No Comments Repeated a grade? Been placed in special education classes? Been diagnosed with learning disability or ADD? Had a significant childhood illness? Been in a car accident? Lost consciousness for any reason? Been exposed to fumes, radiation, or insecticides? Please list any medical conditions you have: Please list any surgeries you have had, including the year. Have you ever Yes No Comments Seen a psychologist? Seen a psychiatrist? Been admitted to a psychiatric hospital? Been in a rehab program? Family History: Has anyone in your family had any of the following conditions? (If yes, please list your relationship with them) Depression Diabetes Anxiety Parkinson s Disease Bipolar Disorder Alcoholism/Drug Abuse Schizophrenia Heart Condition Epilepsy High Blood Pressure Stroke High Cholesterol Migraines Asthma Alzheimer s Dementia Hypothyroidism Other Dementia Hyperthyroidism Liver Condition Cancer Kidney Condition Other Social History: Please list the other members of your household. Are there any pets in the home? If yes, are you allergic?
What school do or did you attend? Do you play sports? If yes, are they affiliated with the school or other organization? Do you have access to a Certified Athletic Trainer? (Please list contact information, if possible) Do you exercise? NEVER RARELY REGULAR, AEROBIC WALK A LOT What is the highest level of education you received? Are you working? How would you describe your work environment? SUPPORTIVE TOXIC UNPREDICTABLE OTHER Did you ever serve in the military? Do you wear glasses or contacts? Are you a smoker? YES NO PREVIOUS Do you consume alcohol? NEVER 1 3 DRINKS/WEEK 4 6 DRINKS/WEEK 7+ DRINKS/WEEK Did you ever use illicit drugs? YES NO PREFER NOT TO SAY Do you drink caffeinated drinks (coffee, tea, energy drinks, soda, etc.)? YES NO If yes, how many cups per day? Please list any allergies you have. Please list your current prescription medications and their doses. Please list your current over the counter medications and their doses. Please list any vitamins or supplements you are currently taking.