Department of Neurology New Patient Memory Form
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- Mabel Stephens
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1 Department of Neurology New Patient Memory Form FIRST NAME: LAST NAME: DATE OF BIRTH: PRIMARY CARE PROVIDER & CLINIC: PREVIOUS NEUROLOGIST: WHY ARE YOU SEEING A NEUROLOGIST? QUESTIONS YOU HAVE FOR YOUR NEUROLOGIST: WHEN DID YOUR MEMORY PROBLEMS START: WHAT WAS NOTICED AND WHO NOTICED: WHAT WAS THE LAST GRADE YOU COMPLETED IN SCHOOL? High School or GED Some College Associates Degree Bachelors Degree Masters Degree Professional Degree DESCRIBE ANY LEARNING DISABILITIES OR STRUGGLES YOU HAD IN SCHOOL? 1 of 7 Please complete all pages
2 CAN YOU DO THE FOLLOWING ACTIVITIES: can still do with no difficulty some difficulty due to memory can no longer do due to memory never did this activity cannot do for other reason date difficulty started Work Drive Manage Finances (balance checkbook, pay bills, etc.) Chores Grocery Shop Socialize/converse with friends Personal hygiene (shower, getting dressed) Taking medications Cook or prepare meals Eat meals without assistance HAVE YOU HAD ANY OF THE FOLLOWING: Mood changes Trouble walking or falls Personality changes Vision changes Hallucinations Tremor Trouble sleeping Using illegal drugs Seizures Prior head injury Staring spells or episodes of confusion History of infection in brain (meningitis) Periods of time with excessive alcohol use 2 of 7 Please complete all pages
3 PERSONAL HABITS: Do you drink alcohol? If yes: Regularly Socially Hard liquor 1-3 oz per day over 3 oz per day Beer 1 bottle/can per day 2 bottles/cans per day 3 or more bottles/cans per day Wine 1-2 glasses per day 3-5 glasses per day more than 5 glasses per day Do you consume more than 5 drinks within a 24 hour period? How many days in the last 6 months did you consume more than 5 drinks in a 24 hour period? Do you smoke? Have you smoked in the past? Do you or have you used recreational / illicit drugs? If yes, what have you used? When did you last use above substance? Do you drink caffeinated drinks? If yes, list how many per day of the following: Coffee; Tea; Soda; Energy Drinks MEDICATION HISTORY Please list all MEDICATIONS you take routinely, prescribed or over-the-counter, along with the dosages: (If you are a Portland Clinic patient and our list is up to date leave blank) Medication: Dose: Frequency: Please list all allergies and sensitivities (e.g. medications, foods, latex, iodine, etc.) 3 of 7 Please complete all pages
4 PAST MEDICAL HISTORY: Have you had or do you have any of the following conditions? Alcoholism High Blood Pressure Arthritis Headache Asthma Hepatitis Cancer Heart Attack Chest Pain Jaundice Colitis Kidney Disease Depression / Anxiety Other Heart Disease Diabetes Pain (Chronic Drug Addiction Rheumatic Fever Emphysema Stomach Ulcers Frequent Kidney Infections Thyroid Disease Frequent Bladder Infections Trouble Sleeping Gallbladder disease Suicidal Thoughts Gout Other SURGERIES: (List procedure and approximate year) Procedure Year Procedure Year 4 of 7 Please complete all pages
5 CURRENT SYMPTOMS - IN THE LAST 6 MONTHS: (please mark all that apply) 1. Head, Eyes, Ears, se, Throat, Lymph des: Headaches Deafness Double vision Hoarseness of voice Tinnitus (buzzing or humming) Photophobia (light bothers eyes) Swollen and/or painful lymph nodes Head trauma Neck swelling Pain and/or drainage from ears Nasal and/or sinus congestion Visual loss or change se bleeds Neck stiffness Sneezing Sore throat Glaucoma Teethe grinding / clenching Headaches Hearing problems Vision problems Dental problems Sinus problems 2. Respiratory System: Shortness of breath Sputum/secretion production Wheezing Cough Hemoptysis Breathing difficulty 3. Cardiovascular System: Chest pain, discomfort, heaviness, tightness Shortness of breath with exertion PND (waking up short of breath) Orthopnea (sleeping on two or more pillows) Leg swelling High blood pressure Palpitations Chest pain Heartburn 4. Gastrointestinal System: Anorexia (poor appetite) Nausea and/or vomiting Constipation or diarrhea Weight loss or gain Hematochezia (red blood in bowel movements) Melena (black bowel movements) Jaundice Abdominal pain Dysphagia (difficulty swollowing) Stomach pain Weight change: loss lbs, gain lbs 5. Genitourinary System: Hematuria Oliguria (infrequent urination) Incontinence Heavy menstrual flow Polyuria (urination of large volumes of urnie) cturia (urination at night) Frequency (frequent urination) Pyuria (cloudy urine) Urgency (sensation to urinate) Sexual dysfunction Symptoms of menopause Irregular periods PMS Bladder problems Excessive urination or thirst 5 of 7 Please complete all pages
6 6. Nervous system: Weakness/paralysis one side of body Urinary and/or fecal incontinence (wet or soil underwear) Memory loss, sleep disturbance, mood disorders (anxiety, depression) Insomnia Snoring Daytime sleepiness Sleep apnea Seizures / shaking Numbness Loss of consciousness Dizziness 7. Musculoskeletal System: Joint pain / swelling / redness Muscle aches and pains Back pain Neck pain Leg / foot cramps Leg restlessness Weakness 8. Dermatological System: Rash Mole changes Pigmentation (change in color) Breast pain Pruritus (itching) Breast lumps Bleeding or bruising Changes in nipples Breast lumps / discharge Allergic reaction Change in skin / hair 6 of 7 Please complete all pages
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AUSTIN RETINA ASSOCIATES PATIENT INFORMATION NAME: MAILING ADDRESS or NURSING HOME NAME & ADDRESS: Last First Middle Initial CITY: STATE: ZIP CODE: - TELEPHONE: HOME:( ) CELL: ( ) WORK:( ) DATE OF BIRTH:
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On behalf of the Spine Center team, we would like to welcome you. At the Spine Center we strive to give our patients exceptional, state-of-the-art care. Although we have received the national recognition
SPINE PATIENT HISTORY FORM
Trenton Orthopaedic Group 116 Washington Crossing Road 1225 Whitehorse-Mercerville Road Pennington, NJ 08534 Bldg. D., Suite 220 Mercerville, NJ 08619 22-1897695 SPINE PATIENT HISTORY FORM Please print
New Patient Evaluation
What area hurts you the most? (Please choose one) When did this pain start? Neck Other: Back How did this pain start? How often do you experience this pain? Describe what this pain feels like. What makes
Hello, Please note: The following information will be needed at your appointment:
Hello, You are receiving this mailing because you or a family member have an upcoming appointment at the Albany Medical Center s Neurology Group as noted above. Our goal is to provide you with the best
OrthoVirginia Registration Information 2016
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Rehabilitation Medicine Clinic. New Patient Questionnaire
Rehabilitation Medicine Clinic (Please complete this 5-page form and bring to your appointment.) Date Appt. Date Age Date of Birth Name Male Female Hand dominance: R L Home Address Home Phone ( ) Work
Please review, complete, and return all paperwork included in this packet. If you have any questions or concerns please feel free to contact us at
Your child has been referred to the Health4Life Program at Children's Healthcare of Atlanta. We are located at the Scottish Rite Campus in the Medical Office Building. In order to serve you and your child
Chemotherapy Side Effects Worksheet
Page 1 of 6 Chemotherapy Side Effects Worksheet Medicines or drugs that destroy cancer cells are called cancer chemotherapy. It is sometimes the first choice for treating many cancers. Chemotherapy differs
Name Home phone Work phone. Address. Email address. Date of birth Gender (circle): M F Marital status No. of children. Name of partner Referred by
Name Home phone Work phone Address Email address Date of birth Gender (circle): M F Marital status No. of children Name of partner Referred by Have you ever seen a Chiropractor? No Yes (Who?): Insurance
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PLEASE PRINT PATIENT LAST NAME: FIRST NAME DATE OF BIRTH: / / AGE: ADDRESS: APT CITY STATE ZIP HOME PHONE # CELL PHONE # WORK PHONE # SEX M F MARITAL STATUS DRIVER S LICENSE # SOCIAL SECURITY # - - EMPLOYER
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Mona Mikael, Psy.D., PSY 25089 Neuro- Rehabilitation Psychologist Neuro- Rehab Psychological Consultation & Treatment 630 S. Raymond Ave., #340 Pasadena, CA 91105 626-710- 7838 Web: www.neurorehabtlc.com