75 Pringle Way, Suite 701, Reno, Nv89502, 775-329-4060, 775-329-2715 (F)

WILLIAM TORCH, M.D.

75 PRINGLE WAY, SUITE 701, RENO, NV89502, 775-329-4060, 775-329-2715 (F)

All of the following information is required. All information provided is strictly confidential.

Please print clearly

Referring Doctor:______

Patient information:Today’s Date: ______/______/______

Patient Name:______Date of Birth:____/____/____

Social Security #:______(please circle one) Male Female

Patient Address:______

Address City State Zip

Mailing Address :______

(If different from above) Address City State Zip

Telephone: Home:______Cell:______Work:______

Insurance Company:______ID#:______

Group #:______Relationship to patient:______

Subscriber’s name:______Subscriber’s Date of Birth:______

Subscriber’s Social Security Number:______Subscriber’s Employer:______

Employer’s Address/Phone number:______

Secondary Insurance Company:______ID#:______

Group#:______Relationship to patient:______

Subscriber’s name:______Subscriber’s Date of Birth:______

Subscriber’s Social Security Number:______Subscriber’s Employer:______

Guarantor Information/Parent/Guardian:

Name:______Relationship to patient:______

Address:______

Address City State Zip

Mailing Address :______

(If different from above) Address City StateZip

Telephone: Home:______Cell:______Work:______

Emergency Contact Information:

Name:______Relationship to patient:______

Address:______

Address City StateZip

Telephone: Home:______Cell:______Work:______

WashoeSleepDisordersCenter

(Northern Nevada’s FirstFully-AccreditedSleepDisordersCenter)

Neurodevelopmental & NeurodiagnosticCenter

75 Pringle Way Suite 701, Reno, NV89502

775-329-4060

William C. Torch, M.D.

Diplomate American Board

Of Psychiatry and Neurology

Consultant in Neurology

With Special Competence in

Child Neurology

Today’s Date: ______/______/______

Patient Name:______Age of Patient:______

Sex (please circle one): Male Female Referring Doctor:______

Who is giving patient history:______

Describe Major Complaint or Problems:______

______

Describe in your own words present illness:______

______

Page 1

Patients name:______Date:______

Doctor’s obtained History:

______

Page 2

INITIAL NEUROLOGICAL EVALUATION

Patient’s Name:______Date:______

Past Medical History:

Mothers Pregnancy of Patient

Gestation Period: Number of Months______Premature______Full Term______

Activity in Utero: Normal______Abnormal______

Illness:

1st Trimester: Months 1 to 3 ______

2nd Trimester: Months 4 to 6 ______

3rd Trimester: Months 7 to 9 ______

Drugs/Habits:

Of Mother:______

Of Father:______

Trauma:

Of Mother or Embryo (if any)______

______

Complications (if any):______

______

Birth/Delivery History of Patient:

Where Delivered:______

Labor:______

Presentation:______

Complications (if any please list age):

Jaundice______Hypoxia______Infection______Other______

Birth Weight:______Apgars (if known)______

Length of Hospitalization______

Postnatal Complications (if any)______

______

Developmental milestones of patient (try to remember approximate age):

Gross Motor:

Rolled Over:______Sat by self______Stood by self______

Walked:______Ran:______Tricycle______

Bicycle:______Walked steps:______

Fine Motor:

Reached 1 hand:______Passes hand/hand ______Pincher Grasp______

Scribbles______Copies______2 Blocks______

Social______Smiled______Reaches______

Indicated wants______Used cups______Fed self______

Washed Self______Toilet Trained______Dressed self______

Language______Squeals/laughs______Mama/Dada______

2-word sentences______Knows name______3-word sentences_____

Knows sentences______

Childhood & Minor illnesses: (Please circle yes or no and indicate age)

Chicken Pox Yes No Age______Viral Illness Yes No Age______

Measles Yes No Age______Colds Yes No Age______

Mumps Yes No Age______Ear infections Yes No Age______

Tonsillitis Yes No Age______TonsillectomyYes No Age______

Meningitis Yes No Age______Encephalitis Yes No Age______

Urinary tract infection Yes No Age______

Other illnesses ______Age______

Page 3

INITIAL NEUROLOGICAL EVALUATION

Patient’s Name:______Date:______

Past Medical History Continued

Major Illnesses (Please list age and first conditions):

______

History of Trauma to the head, spine, body, etc:

______

Obstetrical & Gynecological history (for female patients):

______

Hospitalization/Surgery of Patient:

Date Age Where Reason/Diagnosis/Outcome

______

Medications & Drugs Currently on (List name, Dose Times taken & prescribing doctor)

______

Drug Abuse History:

Have you had any addiction to street drugs, alcohol, prescribed medications?

If so please list name of drug, medication, alcohol, dosage, effects, past and present usage.

______

12.Cigarettes (Please list number of cigarettes or packs per day, plus duration of smoking history):

______

13.Vaccinations:

Up to date (please circle) Yes No Last Vaccine:______Where:______

Reactions:______

14.Allergies (please describe):

______

Page 4

Sleep Study Questionnaire

Patient’s Name:______Date:______

Sleep Habits: / Excessive Daytime Sleepiness
1. Time you usually go to bed and get up:
On weekdays: go to bed:______get up:______
On weekends: go to bed:______get up:______
2. Average time it takes to fall asleep at night: ______
3. Average time asleep at night:______
4. Upon awakening do you fee refreshed/rested?
Yes______No______
5. Difficulty Falling Asleep: Yes______No______
Difficulty Staying Asleep: Yes_____ No______
6. Are you a restless sleeper? Yes______No______
7. Awake frequently from sleep during the night?
Yes______No______
If yes, how many times and what is the cause?
______
8. Ever awakened from sleep, choking or gasping for
Breath? Yes______No______
9. Often wake up with morning headaches?
Yes______No______
10. Sweat a lot at night without actually being
hot? Yes______No______
11. Ever been told that you stopped breathing
while asleep? Yes______No______/ 1. Is daytime sleepiness a problem?
Yes______No______
2. Does Sleepiness interfere with:
You work: Yes______No______
Your social life: Yes______No______
3. Does fatigue interfere with your social life?
Yes______No______
4. Frequent drowsiness or tendency to fall asleep
While driving? Yes______No______
5. Have you ever suddenly fallen, or experienced
Sudden bodily weakness when you get really
Excited, tickled, or angry?
Yes______No______
If yes, how often?______
6. When you are falling asleep, do you ever see vivid
Life-like images? Yes______No______
7. Do you ever awaken and have the feeling that you
Can’t move or are paralyzed?
Yes______No______
If yes, how often?______
THE EPWORTH SLEEPINESS SCALE
How likely are you to doze off or fall asleep in the following situations as opposed to just feeling tired? This
Refers to your usual way of life in the recent times. Even if you have not done some of these things recently, try
To work out how they would have affected you. Use the following scale to choose with most appropriate
Number of each situation.
Situation Chance of Dozing Scale
Sitting and reading ______0=No Chance
Watching TV ______1=Slight Chance
Sitting inactive in a public place(theater/meeting) ______2=Moderate Chance
As a passenger in a car for an hour without a break ______3= High Chance
Lying down to rest in the afternoon(when circumstances allow) ______
Sitting and talking to someone ______
Sitting quietly after lunch without alcohol ______
In a car while stopped in traffic for a few minutes ______
Total ______

COMMUNICATION WITH FAMILY & OTHERS INVOLVED IN YOUR CARE

Please list any family members or others who may be involved in coordinating your care or payment

for your care. Also indicate what kinds of information may be shared with each individual:

NameRelationship to patient Type of information (please circle one)

______All Scheduling Medical Billing RX

Specific Instructions or Limitations:

______

We will continue to rely on the information on this form when communicating with family members

or others involved in your care unless you request changes. Please promptly notify our office if you

wish to alter the designations above.

______

Signature of Patient/Legal RepresentativeDate

______

Print Name Relationship to patient

Neurodevelopmental & Neurodiagnostic/WashoeSleepDisordersCenter

75 Pringle Way, Suite 701

Reno, NV89502

(775) 329-4060

ASSIGNMENT OF BENEFITS AND RELEASE OF MEDICAL INFORMATION

Assignment of Benefits:

I hereby authorize any benefits/payments directly to Neurodevelopment & Neurodiagnostic/Washoe

SleepDisordersCenter and providers of services related to this medical treatment from any medical

insurance company or benefits payable by any other entity due to me. This authorized payment shall

not exceed the balance due to the provider’s regular charges for this period of medical services. I

understand I am financially responsible to the providers for charges not covered by this authorization.

______

Signature of Patient or Parent/GuardianDate

Release of Information:

I hereby authorize release of information of Neurodevelopmental & Neurodiagnostic/WashoeSleep

DisorderCenter and all providers of services related to this medical treatment for all or part of the

patient’s record to any person or corporation which is or may be liable under a contract to the provider

or the patient for all or part of the provider’s charges. Part of our service to you is to complete FMLA/disability paperwork. We charge a fee of $20, which is due upon receipt of the paperwork.

______

Signature of Patient or Parent/GuardianDate

______

Relationship to patient

WashoeSleepDisordersCenter

(Northern Nevada’s FirstFully-AccreditedSleepDisordersCenter)

Neurodevelopmental & NeurodiagnosticCenter

75 Pringle Way Suite 701, Reno, NV89502

775-329-4060

AGREEMENT FOR PRESCRIPTION REQUESTS AND USE OF CONTROLLED SUBSTANCE

Although the majority of our patients control their medication well and follow their provider’s order very

strictly, there are some patients that are prone to harmful medication dependency or addition. Because of this

the State and Federal Governments carefully regulate many pain medications. This means that the sue of

these medications involve mutual responsibility between the patient and physician.

IT IS VERY IMPORTANT THAT YOU READ AND UNDERSTAND THE FOLLOWING POLICIES

AND PROCEDURES. THEY MUST BE FOLLOWED STRICTLY FOR YOUR PROVIDER TO

PRESCRIBE AND TREAT YOU SAFELY AND EFFECTIVELY:

1.Medication must be used as prescribed and directed unless discussed with your physician. It is life

Threatening to chew or take a partial tablet of a long-acting medication. Increasing your dose

without close supervision of your physician could lead to drug overdose, severe sedation,

respiratory, depression and death.

2.If you have a reaction to your medication DO NOT FLUSH IT OR THROW IT AWAY. You

may be required to bring the remainder to the office in order to replace with a new prescription.

3.Per the Board of Medical Examiners Regulations, Sec. 1, Chapter 630 and our office policy,

Controlled substance medications are to be obtained from only one physician. It is a FELONY to

knowingly obtaincontrolled medications from one practitioner without disclosing this fact to all

prescribing practitioners.

4.You should discuss any medication changes with your physicians at your appointments and inform

them of any new medication allergies.

5.Lost, stolen or misplaced prescriptions or medications may not be replaced. Early requests for refills

will be provided unless you have called and discussed this prior to running out of medication. Selling

medication or sharing medication with family, friends, or any other person is illegal and will not be

tolerated. You should protect and care for your medication like you would any other extremely valuable possession. If you run outof your medication either because of poor planning or taking in excess of what

was prescribed, you are responsible for the consequences, including poor pain control and any withdrawal symptoms.

6.If we suspect you are abusing or becoming dependent on medications we may, from time-to-time, run

a DEA report on you.

7.Prescription requests will be addressed Monday through Thursday, 9-5 only. Prescriptions are

not available Friday, weekends, holidays or after business hours. The on-call physician is on-call for

emergencies only.

8.Notify your provider if you are pregnant.

9.The use of alcohol or recreational drugs while on opioids is forbidden. Our office will not provide

Medications under these circumstances.

PHARMACY REFILLS: We require that you contact your pharmacy to fax over the refill request. DO NOT

call our office first. Refills are processed within 48 hours. However, it may take up to 7 days. Please plan

your refills accordingly.

OUT OF MEDICATIONS: We require that you be seen by either Dr. Torch or Christy every three months if

you are asking a Schedule II medication. If you run out of your medications prior to your next scheduled

appointment, you will need to make an interim appointment. WE DO NOT REFILL SCHEDULE II

MEDICATIONS WITHOUT AN APPOINTMENT.

Controlled Substance and Prescription Policy: I have read, understand and accept the stated pain medication

and Prescription Agreement. Any and all of my questions have been answered and I agree that failure to abide

by any of these will be considered a breach of this contract and, at the sole discretion of my physician, may

result in termination of the physician-patient relationship.

Signature of Patient or Responsible Party:______Date:______

Witness of Signature:______Date:______

Printed Name of Patient:______

WashoeSleepDisordersCenter

(Northern Nevada’s FirstFully-AccreditedSleepDisordersCenter)

Neurodevelopmental & NeurodiagnosticCenter

75 Pringle Way Suite 701, Reno, NV89502

775-329-4060

APPOINTMENT AND CANCELLATION POLICY

At Neurodevelopmental & NeurodiagnosticCenter, our goal is to provide quality neurological care

in a timely manner. We have implemented an appointment/cancellation policy which enables us to

better utilize available appointments for our patients in need of our care.

Scheduled Appointments:

To schedule an appointment, please call:

775-329-4060

Cancellations of Appointments:

Please be courteous and call our office promptly if you are unable to attend an appointment. This

time will be reallocated to someone who is in urgent need of treatment.

If it is necessary to cancel your scheduled office appointment we require that you give at least 24

hours notice. Available appointments are in high demand and your early cancellation will give

another person the possibility to have access to timely neurological care.

Any cancellations not made prior to the 24 hours will be subject to a fee of $25.00 and this fee

will not be billed to the insurance.

How to cancel your appointment:

To cancel appointments with our office please call us at 775-329-4060.

No show policy:

A “no show” is someone who misses an appointment without canceling it by 10:00 am, (1) one

working day in advance. No-shows inconvenience those individuals who need access to care in a

timely manner.

A failure to present at the time of a scheduled appointment will be recorded in the patients’ chart

as a “no show”. A fee of $25.00 will be charged to the patient and this fee will not be billed to the

insurance. Three “no shows” may result in the temporary suspension of services.

Thank you for the opportunity to serve you.

Directions from the South

1.Take US-395 North toward RENO

2.Take exit #67 / GLENDALE AVE – go 0.3 miles

3.Turn Left on E 2nd ST. – go 0.6 miles

4.Turn Left on PRINGLE WAY

5.Turn right on PRINGLE WAY

6.Arrive at 75 PRINGLE WAY, RENO, on the Right

Directions from the North

1.Take US-395 South

2.Take exit #67/GLENDALE AVE-go < 0.1 miles

3.Take Right fork onto E 2ND ST – go 0.5 miles

4.Turn Left on PRINGLE WAY

5.Turn Right on PRINGLE WAY

6.Arrive at 75 PRINGLE WAY, RENO, on the Right

Directions from the West

1.Take I-80 EAST

2.Take exit #14/WELLS AVE- go 0.2 miles

3.Turn Right on N WELLS AVE – go 0.6 miles

4.Turn Left on E 2nd ST – go 0.5 miles

5.Turn Right on PRINGLE WAY

6.Turn Right again on PRINGLE WAY

7.Arrive at 75 PRINGLE WAY, RENO, on the Right

Directions from the East

1.Take I-80 WEST

2.Take exit #15/CARSON CITY/SUSANVILLE onto US-395 SOUTH towards CARSON CITY- go 1.4 miles

3.Take exit #67/GLENDALE AVE- go < 0.1 miles

4.Take Right fork onto E 2ND ST- go 0.5 miles

5.Turn Left on PRINGLE WAY

6.Turn Right on PRINGLE WAY

7.Arrive at 75 PRINGLE WAY, RENO, on the Right