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Mark L. Gordon, M.D.
PATIENT INTAKE FORM |
Please Fill Out Completely!
I agree
to using TeleHealth.
I am
a Veteran.
I am
presently on Active Duty.
I am
receiving Medi-Care benefits.
My case
is URGENT. Please start my program Now.
Last Name
*
First Name
*
Date of Birth
*
Email
*
Skype Name
Telephone
*
Street
City
Zip
Country
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Bahamas
Brazil
Canada
Dominican Republic
Israel
Kuwait
Maldives
Mexico
Monaco
Morocco
Nigeria
Oman
Puerto Rico
Qatar
Saudi Arabia
South Africa
Thailand
United Arab Emirates (U.A.E.)
United Kingdom
United States
Virgin Islands (U.S.)
State
- Select State -
Refer me if available:
- Select Refer Me -
Remote Draw
Refer me if available
Head Trauma History
Symptoms:
- Select Symptoms -
G1 = Fatigue,Insomnia,depression,anger,mood issues
G2 = G1 plus loss of libido
G3 = G2 and cognitive impairment.
G4 = G3 plus physical handicap.
Number of TBI:
- Select Number of TBI -
Single Trauma
Multiple Traumas
No physical Trauma
Condition:
- Select Condition -
NO loss of consciousness
Dazed and Confused
Loss of Consciousness
COMA
Medically Induced COMA
Date of TBI(s):
- Select Date of TBI(s) -
Less than 6 months
Greater than 6 months
Greater than 5yr
Greater than 10yrs
Unknown
Type of Injury:
(Multiple selections allowed)
Describe TBI:
Glasgow Score:
- Select Glasgow Score -
Unknown
15
13-14
10-12
< 10
< 8
Status:
- Select Status -
No Physical Impairment
Physically Impaired; able to walk.
Physically Impaired; unable to walk
Bedridden
Wheel Chair
Medical Care Received
Initial Care:
- Select Initial Care -
No care (went home)
Field Hospital
Emergency Room
Hospitalized
Medical Office Visit
Subsequent Care:
- Select Subsequent Care -
None received
Within a WEEK
Within 6 Month
Greater than 6 Months
Hospitalized:
- Select Hospitalized -
No Hospitalization
< 7 days
< 30 days
< 90 days
< 180 days
Other
Medication:
- Select Medication -
No Medication
On Medication(s)
List Medication:
OTHER ISSUES:
We must have your Physician's Information for Treatment.
My Physician is:
MD Phone#:
MD address :
MD City:
MD Zip:
MD Country:
- Select MDCountry -
Bahamas
Brazil
Canada
Dominican Republic
Israel
Kuwait
Maldives
Mexico
Monaco
Morocco
Nigeria
Oman
Puerto Rico
Qatar
Saudi Arabia
South Africa
Thailand
United Arab Emirates (U.A.E.)
United Kingdom
United States
Virgin Islands (U.S.)
MD State:
- Select MD State -
Referred by:
- Select Referred by -
Not Referred
Warrior Angel Foundation
Task Force Dagger
Military Organization
Joe Rogan PodCast
One of your patients
ML Gordon
My Physician
Friend
My Lawyer
Other
Name:
Legal Status:
- Select LegalStatus -
Never Litigated
Active Litigation
Closed Litigation
If Active Litigation:
Lawyers #:
Submit
Thank You
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