Department of Neurology New Patient Memory Form

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Transcription:

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

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

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

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

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. 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

PATIENT HEALTH QUESTIONNAIRE-9 (PHQ9) Over the last two weeks, how often have you been bothered by any of the following problems? (use ü to indicate your answer) t at all Several days More than half the days Nearly every day 1. Little interest or pleasure in doing things 2. Feeling down, depressed, or hopeless 3. Trouble falling or staying asleep, or sleeping too much 4. Feeling tired or having little energy 5. Poor appetite or overeating 6. Feeling bad about yourself - or that you are a failure or have let yourself or you family down 7. Trouble concentrating on things, such as reading the newspaper or watching television 8. Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual 9. Thoughts that you would be better off dead or hurting yourself in some way For office coding: 0 + + + = Total Score: If you checked off any problems, how difficult have these problems made it for you to do your work, take cafre of things at home, or get along with other people? t difficult at all Somewhat difficult Very difficult Extremely difficult 7 of 7 Please complete all pages

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