"Neurology History Form - Stillwater Medical Group"

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Stillwater Medical Group - Neurology History Form
Welcome to our neurology clinic! The nervous system is very complex, and to serve you
better, it’s important that I learn about your medical history, both problems you have now and
medical problems you’ve had in the past. Thank you very much for your patience in filling out this
form before your appointment, even if this information is already in your chart.
Name___________________________________Date of Birth______________Today’s date________
Who referred you to a neurologist?_________________________________________________
Name of your primary care physician:_______________________________________________
Which hand do you use most or dominantly? (circle) Right
Left
Ambidextrous
------------------------------------------------------------------------------------------------------------------------
1. Please describe in detail, the problem or symptoms for which you’re being
Physician
seen today by the neurologist. (symptoms you’re having, what body part it
Notes
affects, how often it happens, how severe, etc.)
Copies of note to:
Please
2. When did this problem start (date) and how old were you then?
do not
write
3. Is there anything that triggered this problem?
in
4. Does anything make this problem better?
this
space.
5. Describe any of the following treatments you’ve tried and did they work?
Self care you’ve tried:
Medications:
Physical Therapy:
Surgery:
Other treatments (e.g. chiropractic or other):
4. What diagnostic tests have been done so far? (e.g. blood work, MRI, EMG,
EEG, etc.)
6. Have you seen a neurologist before for this problem? If so , what is the
neurologist’s name/location? _______________________________________
7. Date(s) you saw this doctor:_____________________________________
Page 1 of 4
filename: Neurology Intake form
Last saved by Donna M. Koning 2/25/2009
Stillwater Medical Group - Neurology History Form
Welcome to our neurology clinic! The nervous system is very complex, and to serve you
better, it’s important that I learn about your medical history, both problems you have now and
medical problems you’ve had in the past. Thank you very much for your patience in filling out this
form before your appointment, even if this information is already in your chart.
Name___________________________________Date of Birth______________Today’s date________
Who referred you to a neurologist?_________________________________________________
Name of your primary care physician:_______________________________________________
Which hand do you use most or dominantly? (circle) Right
Left
Ambidextrous
------------------------------------------------------------------------------------------------------------------------
1. Please describe in detail, the problem or symptoms for which you’re being
Physician
seen today by the neurologist. (symptoms you’re having, what body part it
Notes
affects, how often it happens, how severe, etc.)
Copies of note to:
Please
2. When did this problem start (date) and how old were you then?
do not
write
3. Is there anything that triggered this problem?
in
4. Does anything make this problem better?
this
space.
5. Describe any of the following treatments you’ve tried and did they work?
Self care you’ve tried:
Medications:
Physical Therapy:
Surgery:
Other treatments (e.g. chiropractic or other):
4. What diagnostic tests have been done so far? (e.g. blood work, MRI, EMG,
EEG, etc.)
6. Have you seen a neurologist before for this problem? If so , what is the
neurologist’s name/location? _______________________________________
7. Date(s) you saw this doctor:_____________________________________
Page 1 of 4
filename: Neurology Intake form
Last saved by Donna M. Koning 2/25/2009
Physician’s notes
Past Medical History: P
lease check if you’ve ever had any of these
neurological or muscle illnesses:
____Headaches
____ Seizures
____Concussion
____Spells of loss of consciousness
____Stroke
____TIA (stroke that ‘went away’)
____Carotid stenoses
____Brain aneurysm
____Bleeding in or around the brain
____Brain surgery
____Brain tumor
____Brain radiation treatments
____Carotid or other dissection ____Meningitis
____Vision loss or optic neuritis
____Multiple Sclerosis
____Head injury
____Other neurologic infections
____Parkinson’s
____Tremors
____ Sleep disorders
____Muscle diseases
____Neuropathy
____Problems with walking
Please
____Genetic or inherited neurologic disease
____neuromas or neurofibromas
do not
Have you had any neurological or muscular illness not listed above?
write
in
this
Other Past Medical History: Please check if you have ever had …
space.
_____Medical problems you were born with (congenital), please describe
Cardiac or vascular diseases including: ____Heart trouble
____High blood pressure
____High cholesterol
____Other clogged arteries (peripheral vascular disease)
____Atrial fibrillation
____Other heart or vascular problems (describe)____________________________
___________________________________________________________________
Metabolic diseases including: ____diabetes
____thyroid disease
____kidney disease
____liver disease ____B12 deficiency
____other metabolic diseases (describe):__________________________________
Cancer, please describe:_______________________________________________
Other tumors, please describe:_________________________________________
Infections, including: ____meningitis
____encephalitis
____cold sores
____genital herpes
____shingles
____sinus infections
other infections (describe):_____________________________________________
Childhood infections including: ____measles
____mumps
____chicken pox
____rheumatic fever
Immunizations including: ____polio ____Lyme
____tetanus (date_______)
Degenerative diseases including:
____arthritis
____lupus
Other degenerative diseases (describe):___________________________________
__________________________________________________________________
Other illnesses not listed above (describe)_______________________________
_____________________________________________________________________
_____________________________________________________________________
_______________________________________________________________
Surgical operations, please describe:____________________________________
___________________________________________________________________
___________________________________________________________________
Injuries, car accidents, & broken bones (describe and list date)______________
_____________________________________________________________________
_________________________________________________________________
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filename: Neurology Intake form
Last saved by Donna M. Koning 2/25/2009
Physician Notes
Have you ever been hospitalized for any reason? ____yes
____no
Please describe reason for all hospitalizations:
Have you ever been treated for depression, anxiety, or chemical dependency
Please
issues? Please describe and give dates of treatment..
do not
write
Do you have any difficulties with thought disorders such as hallucinations,
in
schizophrenia, etc.? Please describe.
this
space.
MEDICATIONS:
Please list all the prescription medications, vitamin and other supplements,
and herbal medications you take now.
Medication
Dose / how often
Medication
Dose / how often
1.
7.
2.
8.
3.
9.
4.
10.
5.
11.
6.
12.
Drug Allergies or Reactions to medications: Please list any medications to which
you’ve got an allergy or had bad reaction:
FAMILY HISTORY: Does anyone else in your family have a similar problem to
one you are being seen for today?
Please fill in the health history of your blood relatives below:
Relation
Are they
Age
Health problems
Alive?
Yes
No
Mother
Father
Brother or Sister
Brother or Sister
Brother or Sister
Brother or Sister
Brother or Sister
Brother or Sister
Brother or Sister
Son or Daughter
# 1
Son or Daughter
# 2
Son or Daughter
# 3
Son or Daughter
# 4
Son or Daughter
# 5
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filename: Neurology Intake form
Last saved by Donna M. Koning 2/25/2009
SOCIAL HISTORY:
Physician’s Notes
Are you
?
___single
___married
____partnered
___divorced
___widowed
If applicable, how many years have you been or were you married?____________________
Please
Number of children and ages:______________________________________________
do not
What is your occupation? ________________________________________
Education: list highest grade/degree attended:_______________________________
write
Have you ever smoked or chewed?__yes ___no What age did you start?______
in
Do you currently smoke or chew? ____no, I quit (date) ____.
___yes How much per day?______
How much alcohol do you drink per week?__________________________________
this
Have you ever used street drugs or drugs not prescribed to you?______________________
space
What are your significant hobbies or interests?_________________________
REVIEW OF SYSTEMS: Please circle problems you have now or had recently
Neurological: Memory loss, word finding problems, getting lost frequently,
difficulty doing tasks you could do previously, seizures, loss of consciousness,
loss of sense of smell, double vision, dizziness, tinnitus or ringing in your ears,
problems with hearing, slurred speech, problems chewing or swallowing,
change in sense of taste, weakness in part of your body, numbness, incoordination, falls, loss
of balance, pain or tingling, difficulty walking, muscle stiffness, muscle cramps, tremor,
problems controlling movement, muscle jerks or twitches
Ocular: decreased vision, double vision, pain in eyes.
Autonomic: dry eyes, dry mouth; any of these changes when you stand up: dizziness,
weakness, fatigue, mental changes, visaual changes, vertigo, anxiety, heart palpitations,
nausea, fainting
All of these
systems
Blood disorders: anemia, bruising, bleeding gums, recurrent infections, etc.
reviewed, and
Heart: heart attacks, chest pain, shortness of breath, swollen feet, light-headedness,
unless circled
palpitations, atrial fibrillation, etc.
are negative or
noncontributory
Lungs: shortness of breath, spitting up blood, painful breathing, increased phlegm.
Gastrointestinal: any of these changes after eating: early fullness, bloating, nausea,
dizziness, sweating.
Any time: abdominal pain, vomiting blood, dark/tarry bowel movements, heartburn, diarrhea,
constipation;
Urinary / kidneys: incomplete emptying of your bladder, difficulty starting the stream,
losing urine (icontinence), being unable to gopainful urination, blood in urine, pus in urine,
previous history of bladder disease, kidney disease.
Sexual: inability to get an erection, difficulty achieving orgasm, retrograde ejaculation
(painful ejaculation back into the bladder)
Endocrine: diabetes, thyroid disease, B12 deficiency, adrenal insufficiency,
hypertension, problems with calcium metabolism, pituitary problems, excessive thirst,
Skin: rashes, sores, unusual spots or patches of color, skin cancer, melanoma, new lumps or
bumps, changes in skin appearance that come and go
Musculoskeletal: joint pain, muscle pain, joint deformities, frequent fractures, arthritis
Allergic/Immune: allergies, hay fever, sinus problems, frequent infections
Ears, nose, throat: sinus disease, decreased hearing, vertigo, ringing in ears, sores in mouth,
nasal polyps
Psychiatric: anxiety, depression, hallucinations, violent behavior
Constitutional: unexplained weight gain or loss, fever, chills, fatigue, sweats,
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filename: Neurology Intake form
Last saved by Donna M. Koning 2/25/2009
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