Neurology

1
Patient Full Name* This field is required.Format: Last name, First name
2
Health Card NumberLeave blank if you do not have a health card (i.e out of country, refugee etc.)
3
Date of birth* This field is required.Enter in the following format: YYYY-MM-DD. For example: 2020-12-31 for December 31st, 2020
4
Cellphone number* This field is required.Enter phone number WITHOUT any dashes or '1" in front of it. For example: 9058979228. Enter the SAME PHONE NUMBER that you have been receiving text messages from the clinic.
5
Email* This field is required.
example@example.com
6
Current Address including postal code * This field is required.Enter your address with your postal code. For example: Suite 110 - 21 Queensway West, Mississauga, ON L5B1B6
7
What neurological conditions do you have (if any)?If unknown, leave blank.
Headaches
Migraines
Stroke
Epilepsy
Seizures
MS (Multiple Sclerosis)
Parkinson's Disease (and other dementia)
Tremors
Spinal Disorders
Other
8
What are your current symptoms?* This field is required.Ex: Headache, Migraine, etc
9
Where do you feel your symptoms (head, arms, legs, etc.), Please be as specific as you can.* This field is required.Ex. If you have headaches, on front-right side of head, etc.
10
How painful are your symptomsWhen you experience symptoms, do they cause pain and if so, how painful are they to you.
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4Row 0, Column 5Row 0, Column 6
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4Row 0, Column 5Row 0, Column 6
11
When did your symptoms start?
12
What is the frequency of your symptoms (Ex: once a week, twice a month etc) and how long do your symptoms last?Ex: Increasing becoming more consistent
13
Please provide any more information on your symptoms.Any other relevant information such as triggers.
14
Have you had any CT or MRI tests in regards to your neurological symptoms?If yes, please bring the printed report if it is an in person visit or provide a copy of report ahead of your appointment.
YESNO
15
Please provide a list of your current medications (if known).
16
Do you have allergies to any medications?If none, leave blank.
17
If you smoke, please provide the frequency of smoking and amount of smoking.
18
If you drink Alcohol, provide the frequency of drinking and amount of drinking.
19
If you use any recreational drugs, please provide the frequency of drug use and amount as well as type of drugs.
20
Please list all past medical issues you have had that you can recall.
21
Have any family members had any of the following conditions?
Headaches
Migraines
Stroke
Epilepsy
Seizures
MS (Multiple Sclerosis)
Parkinson's Disease
Tremors
Spinal Disorders
Other
22
If you have any family history of any condition, please provide the family relation (ex. mother/sister/father/aunt), and current age or if deceased.For Example; Parkinson's, Aunt (mother's side), passed 2 years ago at age 68.
Huge
Large
Normal
Small
Ok
Ok
Should be Empty: