INFORMATION FOR YOUR PHYSICIAN
PATIENT NAME
TODAY’S DATE
-
Month
-
Day
Year
Date
I. CHIEF COMPLAINT
Please write the reason you came to the doctor at this time:
What is your main symptom?
When did your symptoms start?
Have you had a previous neurological evaluation and, if so, what is the doctor’s name?
Are you seeing us about a motor vehicle accident injury or a work-related injury?
Yes
No
If yes, date of accident/injury
-
Month
-
Day
Year
Date
II. PAST MEDICAL HISTORY
Please check illnesses or conditions YOU have had:
Diabetes
Glaucoma
Heart Trouble
Syphilis
Mental Illness
Cancer
Asthma
Liver disease/Jaundice
Gonorrhea
Bleeding Tendencies
Tuberculosis
Pneumonia
Kidney Disease
Rheumatic Fever
HIV/AIDS
COVID-19
Hypertension
Muscle/Nerve Disorder
Other
Please list other illnesses not requiring operation for which you were hospitalized:
Have you had serious injuries, broken bones, etc.? If so, list:
Have you received a blood transfusion?
Yes
No
Date(s):
-
Month
-
Day
Year
Date
Your weight dressed:
Are you taking oral contraceptives?
Yes
No
Menstrual History: Last period
-
Month
-
Day
Year
(date of onset)
Periods are:
Regular
Irregular
III. SURGICAL HISTORY
Please list, giving dates, hospital where performed, and name of surgeon:
V. FAMILY HISTORY
Please check illnesses which have occurred in any of your blood relatives:
Bleeding Tendencies
Diabetes
Kidney Disease
Tuberculosis
High Blood Pressure
Heart Disease
Mental Illness Allergies
Muscle/Nerve Disorder
Headache
Cancer
Stroke
Other
Father
Living
Yes
No
Age
Age at Death
Present Health
Cause of Death
Mother
Living
Yes
No
Age
Age at Death
Present Health
Cause of Death
Brothers
# Living
Health
# Dead
Cause of Death
Sisters
# Living
Health
# Dead
Cause of Death
# Children Living
Ages and Health
# Children Dead
Ages and Cause
V. MEDICATIONS
Please name or otherwise identify medications either currently or recently used
VI. ALLERGIES
List medications or substances to which you have had allergy or sensitivity
Please describe the allergy/sensitivity:
VII. SOCIAL HISTORY
Age
Place of Birth
Race/Nationality/Ethnic Background
(for hereditary diseases)
Education
(highest level attained)
Occupation
How long
Maiden name
Where and when have you lived or traveled outside of the U.S. or Canada?
Do you use tobacco now?
Yes
No
In the past?
Yes
No
Type and amount
Do you use alcoholic beverages
Yes
No
Type and amount
Do you use recreational or illegal drugs?
Yes
No
Type and amount
Spouse living?
Yes
No
Health/Cause of death
Present marriage – years
Previous marriage – year and duration
Submit
Should be Empty: