Department of Neurology New Patient Form

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Transcription:

Department of Neurology New Patient Form FIRST NAME: LAST NAME: DATE OF BIRTH: PRIMARY CARE PROVIDER & CLINIC: PREVIOUS NEUROLOGIST: I. REASON FOR VISIT - CHIEF COMPLAINT (HISTORY OF PRESENT ILLNESS) Please describe the concern or problem that brings you in today: Is this visit related to worker s compensation? (circle one) Is this visit related to any legal actions? (circle one) If this problem is the result of an accident, when did the accident occur? Do you have any questions for your doctor? II. PAIN ASSESSMENT Do you experience pain as part of your daily life? (circle one) If yes, please describe the location(s), onset, duration, and characteristics of your pain: If yes, on a scale of 1 to 10 (0 = no pain, 10 = the worst pain), how would you rate your pain? 1 of 5 Please complete all pages

III. HISTORY OF FALLS Have you had any significant falls in the past 6 months? If yes, please explain: IV. HANDEDNESS Are you (circle one): Left Handed Right Handed V. FAMILY HISTORY Do you have a family member affected with: Condition Brain Tumor Seizures or epilepsy Dementia Parkinson s Multiple Sclerosis Thyroid Disease Type/affected relative Condition Muscle Disease Neuropathy Other Neurological Disorder Hypertension Diabetes Migraines Type/affected relative Write other conditions: VI. 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.) 2 of 5 Please complete all pages

VII. 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 VIII. SURGERIES: (List procedure and approximate year) Procedure Year Procedure Year 3 of 5 Please complete all pages

IX. 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 X. 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 Current Symptoms Continued on Next Page >> 4 of 5 Please complete all pages

2. Respiratory System: Shortness of breath Sputum/secretion production Wheezing 3. Cardiovascular System: Chest pain, discomfort, heaviness, tightness Shortness of breath with exertion PND (waking up short of breath) 4. Gastrointestinal System: Anorexia (poor appetite) Nausea and/or vomiting Constipation or diarrhea Weight loss or gain 5. Genitourinary System: Hematuria Oliguria (infrequent urination) Incontinence Heavy menstrual flow Polyuria (urination of large volumes of urnie) 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) 7. Musculoskeletal System: Joint pain / swelling / redness Muscle aches and pains Back pain 8. Dermatological System: Rash Mole changes Pigmentation (change in color) Breast pain Cough Hemoptysis Breathing difficulty Orthopnea (sleeping on two or more pillows) Leg swelling High blood pressure Hematochezia (red blood in bowel movements) Melena (black bowel movements) Jaundice Abdominal pain cturia (urination at night) Frequency (frequent urination) Pyuria (cloudy urine) Urgency (sensation to urinate) Sexual dysfunction Insomnia Snoring Daytime sleepiness Sleep apnea Neck pain Leg / foot cramps Leg restlessness Pruritus (itching) Breast lumps Bleeding or bruising Changes in nipples Palpitations Chest pain Heartburn Dysphagia (difficulty swollowing) Stomach pain Weight change: loss lbs, gain lbs Symptoms of menopause Irregular periods PMS Bladder problems Excessive urination or thirst Seizures / shaking Numbness Loss of consciousness Dizziness Weakness Breast lumps / discharge Allergic reaction Change in skin / hair 5 of 5 Please complete all pages

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