NEUROLOGY New Patient History Form

Transcription

1 NEUROLOGY New Patient History Form 220 Cherry Street SE Grand Rapids MI Phone: / Toll Free: Fax: Personal Information: Address: City: State: Zip: Phone: Home: Work: Cell: Age: M/F: Right-handed: Left-handed: Race: Caucasian, African-American, Hispanic, Asian, Pacific Islander, American Indian, or Other Physician Information: Referring Physician: Primary Care Physician: Please list other providers who you would like to receive a report of your visit: GR (logo revised )

2 Neurology New Patient History Form Page 2 Medical Information: Please briefly describe the symptoms that brought you to our office: Please list all CURRENT medications. Include all prescription and non-prescription (over-thecounter) medications, topical medications, aspirin, birth control pills, and supplements. MEDICATION DOSE/FREQUENCY DATE STARTED REASON Do you have any ALLERGIES to medications? NO YES (please list below) Past Medical History: High Blood Pressure Diabetes Stroke Heart Disease Blood Disorder Brain Tumor Migraine Headaches Thyroid Disease Seizure Depression Radiation Cancer Chemotherapy Lupus High Cholesterol 2

3 Neurology New Patient History Form Page 3 Past Surgical History: Please list all SURGERIES and approximate dates: Social History: Do you live alone? Please circle: Married Single Divorced Widowed Occupation: Please circle: Fulltime Part-time Retired Disabled Tobacco Use: NO YES How much: Alcohol Use: NO YES How often: Drug Use: NO YES Type and frequency: Special Diet? NO YES Type: Do you have stairs in your home? If so, how many? Family History: High Blood Pressure Diabetes Thyroid Disease Heart Disease Blood Disorder Sarcoidosis Migraine Headache Amyotrophic Lateral Sclerosis Seizure Depression Dementia Cancer Multiple Sclerosis Rheumatoid Arthritis Parkinson s Disease High Cholesterol Alzheimer s Disease Stroke Other: Lupus Please note any additional information that you feel would be helpful to the physician: 3

4 Neurology New Patient History Form Page 4 Review of Systems: Please indicate if you currently experience the following. General Genitourinary Fever yes no Frequent urination yes no Chills yes no Urinary hesitancy yes no Sweating yes no Incontinence yes no Loss of appetite yes no Fatigue yes no Gastrointestinal Weight loss yes no Nausea yes no Jaw pain yes no Vomiting yes no Tongue pain yes no Diarrhea yes no Joint pain yes no Constipation yes no Muscle pain yes no Musculoskeletal Neurological Back pain yes no Limb weakness yes no Joint pain yes no Numbness yes no Joint swelling yes no Seizures yes no Muscle cramps yes no Tremors yes no Muscle weakness yes no Vertigo yes no Stiffness yes no Brief vision loss yes no Leg pain yes no Falls yes no Headaches yes no Psychiatric Trouble walking yes no Depression yes no Insomnia yes no Anxiety yes no Snoring yes no Memory loss yes no Restless legs yes no Suicidal thoughts yes no Hallucinations yes no Eyes Paranoia yes no Blurred vision yes no Confusion yes no Double vision yes no Vision losses yes no Cardiovascular Eye pain yes no Chest pain yes no Palpitations yes no ENT Fainting spells yes no Ringing in ears yes no Loss of hearing yes no Endocrine Nosebleeds yes no Cold intolerance yes no Heat intolerance yes no Skin Rash yes no Hematologic Suspicious lesions yes no Abnormal bruising yes no Abnormal bleeding yes no Respiratory Allergic/Immunologic Cough yes no Recurrent Infections yes no Difficulty breathing yes no 4

5 Neurology New Patient History Form Page 5 Previous Testing: Please indicate if any of the following have been completed prior to your visit. Bring copies of results, as well as any films or CDs from scans that you have had, to your appointment. TEST DATE LOCATION RESULTS MRI/CT of the head MRI/CT of the Orbits MRI/CT of Neck MRI/CT of thoracic spine MRI/CT of lumbar spine Evoked Potentials Visual Fields EEG Cerebral Angiogram Carotid Doppler Lumbar Puncture Biopsy Blood Tests GR (logo revised ) neuroadmn/rm/neurology/new Patient History/revised date