Texas Minimally Invasive Spine Surgery | Dr. Shaad Bidiwala

Best Dallas Spine Surgeon

Patient Forms

It is very important that we have as much medical information about you as possible before your visit.  In order to expedite your appointment, please fill out the forms below.

Thank you in advance for your help.  We look forward to seeing you soon!

PATIENT INTAKE FORMS

PATIENT INTAKE FORMS

Please complete the following forms for your upcoming appointment with Dr. Shaad Bidiwala. Once completed, please be sure to hit the “submit” button on the bottom of the page. If there are any questions please feel free to call our office staff at 214-823-2052 opt 4.

PATIENT INFORMATION

GENDER
MARITAL STATUS
RACE
LANGUAGE
HOW DID YOU HEAR ABOUT US?

INSURANCE COVERAGE

PRIMARY CARD HOLDER
SECONDARY COVERAGE
SECONDARY CARD HOLDER

EMERGENCY CONTACT

PRIMARY EMERGENCY CONTACT
PRIMARY EMERGENCY CONTACT
First Name
Last Name
AUTHORIZATION PERMISSION OF PHI
SECONDARY EMERGENCY CONTACT
SECONDARY EMERGENCY CONTACT
First Name
Last Name
AUTHORIZATION PERMISSION OF PHI

CIRCLE OF CARE

PHARMACY

MEDICATION ALLERGIES

DRUG ALLERGIES?

CURRENT MEDICATIONS

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REVIEW OF SYSTEMS

DO YOU CURRENTLY HAVE ANY OF THESE SYMPTOMS

PERSONAL HISTORY

PLEASE CHECK BOXES BELOW IF YOU HAVE BEEN DIAGNOSED WITH ANY OF THE FOLLOWING MEDICAL CONDITIONS

FAMILY HISTORY

PLEASE MARK IF ANY IMMEDIATE FAMILY MEMBER HAS BEEN DIAGNOSED WITH ANY OF THE FOLLOWING MEDICAL CONDITIONS.

SOCIAL HISTORY

DOMINATE HAND
DO YOU HAVE A LIVING WILL?
DO YOU HAVE A DNR?
DO YOU HAVE ANY OBJECTIONS TO RECEIVING BLOOD OR BLOOD PRODUCTS?
*IF OVER 65, HAVE YOU HAD PNEUMONIA VACCINE?
DO YOU TAKE ASPRIN?
DO YOU HAVE A PACEMAKER?
DO YOU TAKE A BETA BLOCKER?
*IF OVER 65, HAVE YOU HAD ANY FALLS IN THE PAST YEAR?
HAVE YOU EVER SMOKED?
ARE YOU A CURRENT SMOKER?
WHAT TYPE DO YOU SMOKE?
HAVE YOU HAD AN ALCOHOLIC DRINK THE PAST YEAR?
HOW OFTEN DID YOU DRINK THE PAST YEAR?
HOW MANY DRINKS IN A DAY?
HOW OFTEN DO YOU DRINK 6 OR MORE ON ONE OCCASION IN THE PAST YEAR?
DO YOU CURRENTLY USE ANY RECREATIONAL DRUGS?

PRIOR SURGERIES/PRIOR HOSPITALIZATIONS

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REASON FOR VISIT

CONSERVATIVE THERAPIES

**YOUR INSURANCE COMPANY MAY REQUIRE CONSERVATIVE THERAPIES BEFORE APPROVING SURGERY. THE FOLLOWING INFORMATION WILL HELP WITH THE APPROVAL OF ANY TESTING TO BE ORDERED OR SURGERY IF INDICATED. **
HAVE YOU HAD TO USE A
HAVE YOU TRIED
DIAGNOSTIC IMAGING
**WITHIN 6 MONTHS OF APPOINTMENT DATE**
MEDICATION THERAPIES
***WITHIN THE LAST SIX MONTHS***
TRIGGER POINT INJECTIONS
EPIDURAL STEROID INJECTIONS
FACET JOINT INJECTIONS
WHERE DID YOU RECEIVE THE INJECTIONS?
BOTOX INJECTIONS
**HEADACHE/MIGRAINE PATIENTS ONLY**
HAVE YOU MISSED ANY WORK FOR THIS CONDITION?

TEXAS NEUROSURGERY ACKNOWLEDGEMENT FORM

AUTHORIZE:
PATIENT CONSENT

PHYSICIAN ONLY SECTION –PLEASE DO NOT SIGN HERE–

I HAVE REVIEWED THE LISTED ROS/PFSH/SCREENING WITH THE PATIENT AND NOTED THE POSITIVE/NEGATIVE FINDINGS FOR THE VISIT.

DALLAS OFFICE

Mockingbird Station
6080 N Central Expressway
Suite #150
Dallas, TX 75206
United States

OFFICE LOCATION DETAILS

We sit behind the Beeman Hotel.  Please park in garage on Level 4.  Elevator access available.  We are the first office on the main floor.

DISCLAIMER

The content on this page is for informational purposes only, and is in no way intended to be medical advice. There is no substitute for a face-to-face evaluation by your physician or another qualified practitioner. As always, if you have an emergency, call 9-1-1, or go to the nearest emergency department.