Referral Intake Questionnaire

* indicates a required field

Focused Ultrasound Referral Intake Questionnaire

Patient Name :

Email :

Current Neurologist

Provider Name :

Clinic :

Primary Care Physician

Provider Name :

Clinic :

Secondary Insurance :

Have you been formally diagnosed with an Essential Tremor or Parkinson's Disease?

Diagnosis :

Year Diagnosed :

Do you have a family history of Essential Tremors or Parkinson's Disease? If yes, who?

Dominant hand (Right/Left) :

Side you would like to treat :

What tasks are you having difficulty completing due to your tremor (ex: trouble with eating/drinking, cooking meals, dressing, hygiene, tying shoes, driving, work) Please give several examples :

Do you have a history of falls or balance issues?

Do you have a voice tremor (does your voice quaver when you speak)?

Any issues with swallowing?

Have you or your family noticed that you experience any cognitive difficulty or memory challenges?

What medications have you tried for your tremors (must try a minimum of two medications, or have a contraindication) :

Tried :

Currently Taking :

Have you had prior head or brain imaging (CT or MRI)?

Where?

When?

If you've had an MRI, have you had any difficulties completing the scan? (Difficulty breathing, claustrophobia, pain, difficulty lying flat?)

Do you have any implanted devices (cardiac pacemaker, spinal cord stimulator, DBS device) or metal hardware (pins, rods, shunts, clips) that would prevent you from having an MRI?

If you have a pacemaker, please provide details

Pacemaker manufacturer :

Pacemaker serial number :

Lead manufacturer :

Lead serial number :

Do you have any scaring on your scalp?

Are you willing to shave your head for this treatment (required)?

Are you pregnant?

Do you have any heart conditions?

Do you take medication for high blood pressure?

Do you take any blood thinners? What is the indication?

Do you have Diabetes and take insulin?

What is your primary goal?

What questions do you have?