The IRS Form 090372, also known as the "Notice of Proposed Forfeiture", is a document that is issued by the Internal Revenue Service to notify an individual or organization of the proposed forfeiture of assets. The notice provides detailed information about the assets that are subject to forfeiture and the legal process that will be followed if the assets are not claimed. It is important to note that receipt of a Notice of Proposed Forfeiture does not mean that assets will automatically be forfeited - it simply initiates the legal process. If you have been notified that your assets are subject to forfeiture, it is important to consult with an attorney immediately to discuss your options.
| Question | Answer |
|---|---|
| Form Name | Form 090372 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | 090372 uic neurosurgery form |
UNIVERSITY OF VIRGINIA HEALTH SYSTEM
PLACE LABEL HERE.
0300004 |
IF LABEL NOT AVAILABLE, WRITE IN PT NAME & MR# |
DEPARTMENT OF NEUROLOGICAL SURGERY MEDICAL HISTORY FORM – PEDIATRIC PATIENTS
PLEASE BRING COMPLETED FORM WITH YOU TO YOUR SCHEDULED APPOINTMENT AS WELL AS ALL YOUR MEDICATIONS AND ANY PRIOR MEDICAL RECORDS OR
Please assist in obtaining the most accurate information regarding your medical history by completing the information below. If you have already completed this form for our department, please disregard. Your assistance is greatly appreciated.
GENERAL INFORMATION:Date: _____________________________
Name ________________________________________________________________________________________________________
LASTFIRSTMIDDLE INITIAL
Home Address _________________________________________________________________________________________________
_________________________________________________________________________________________________
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(CITY) |
(STATE) |
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(ZIP CODE) |
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Home Phone ( |
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Work Phone ( |
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Date of Birth:____________ Gender (check one): oMale oFemale Are you: |
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1.Please give the name, address, and phone # of your pediatrician / family Dr. and any referring Dr.’s you would like information sent to: _____________________________________________________________________________________________________
____________________________________________________________________________________________________________
2.What is the main reason for your visit today? _____________________________________________________________________
3. Did you bring medical records, slides, and/or
HISTORY OF PRESENT ILLNESS: Please describe the symptoms of your medical problem.
Location and Severity of Problem: _________________________________________________________________________________
How long have you had the symptoms? _______________________ When do you have the symptoms? _______________________
What makes the symptoms better or worse? ________________________________________________________________________
MEDICAL HISTORY:
1. Term Birth? Yes____ No____ If not, birth at _____ weeks gestation. Method of delivery: Vaginal _____
2. List any medical conditions you have:
MEDICAL CONDITIONS
Condition
When Diagnosed?
Condition Currently Under Treatment
3. Have you ever been hospitalized or had surgery? o No o Yes If yes, please list all previous surgeries and hospitalizations below (include dates and hospitals when possible).
HOSPITALIZATIONS
Date of Hospitalization
Type of Surgery
Reason for Surgery
4.DEVELOPMENTAL HISTORY: (circle all that apply)
Able to hold head up |
Able to sit up unassisted |
Able to follow object with eyes |
Able to crawl |
Able to grasp toy |
Able to feed self |
5.ARE YOU CURRENTLY UNDERGOING:
Physical Therapy o No o Yes |
Occupational Therapy |
Able to imitate speech/sounds |
Able to speak in sentences |
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Able to walk |
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Able to use fork and spoon |
Able to speak simple words |
Able to dress self |
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Able to broad jump |
o No o Yes |
Speech Therapy o No o Yes |
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FORM # 090372 |
CAT: 03 - HEALTH HISTORY |
(ORIG. 03/09) |
To reorder, log onto http://www.virginia.edu/uvaprint |
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6. Do you take any medications? o No o Yes If yes, please list below:
CURRENT MEDICATIONS
Name/Dose/Route of Medication
Date Started Medication
How Often Is It Taken?
Reason for Taking Medication
7. Do you have any known drug allergies? o No o Yes If yes, please list them below:
KNOWN ALLERGIES
Name of Medication
Reaction to Medication
FAMILY HISTORY: (Please list any illnesses that run in your family, including heart disease, diabetes, seizures, or cancer)
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
SOCIAL HISTORY: (Please circle the correct answer) |
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• Education: |
PRESCHOOL |
GRADE SCHOOL |
MIDDLE SCHOOL |
HIGH SCHOOL |
COLLEGE |
Whodoyoulivewith? ___________________________________________________________________________________________
REVIEW OF SYSTEMS: (Please check all that describe your symptoms)
Constitutional |
o Nausea/Vomiting |
o Dry skin |
o Facial weakness |
o Fever |
o Abdominal Pain |
o Loss or gain of body hair |
o Decreased sense of smell |
o Night sweats |
o Incontinence / Constipa- |
o Anxiety |
or taste |
o Weight loss |
tion / Diarrhea |
o Weight loss or gain |
o Difficulty swallowing |
Cardiovascular |
o Excessive thirst |
o Slurred speech |
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o Shortness of breath |
o Burning with Urination |
Hematologic |
o Headache |
o Chest pain |
o Difficulty starting / ending |
o Easy bruising |
o Dizziness |
o Irregular heart beat |
urine stream |
o Nose bleeds |
o Seizures |
Respiratory |
o Poor bladder control of |
o History of excessive bleed- |
Musculoskeletal |
o Chronic cough / Cough- |
incontinence |
ing with previous surgeries |
o Neck pain |
ing blood |
o Loss of sensation of geni- |
Neurological |
o Arm pain / numbness / |
o Bronchitis |
tals |
o Change in vision (blurry, |
weakness |
o Asthma |
o Inability to obtain, maintain |
double) |
o Loss of arm / hand coordi- |
erection |
o Loss of hearing or ringing |
nation |
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o Blood in stool/Dark col- |
Endocrine |
in ears |
o Back pain |
ored stool |
o Nipple discharge |
o Facial numbness |
o Leg pain / numbness |
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Completed by: _________________________________________________________________________________________________
Patient / Parent / Guardian Signature
Reviewed by: _____________________________________________ PIC # ________ Title _______________ Date_______________
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