Patient History - Nassau Suffolk Neurology

Name*

Date*

What is the main reason for your visit today*

Height*

Weight*

Social History:

Marital Status: *

S

M

D

W

Do you have any children? If yes, how many?*

Occupation*

Alcohol Use:*

Yes

No

If yes, please indicate type and amount:*

Street or Illicit Drug Use: *

Yes

No

If yes, please list: *

Have you received treatment for drug/alcohol problems? *

Yes

No

*Do you drink beverages containing caffeine? *

Yes

No

If yes, how many per day? *

*Do you exercise regularly? *

Yes

No

If yes, how many times per week? *

Please list all allergies and reactions: *

Medications:

Please list all of your medications (including dosage and frequency). If you do not take any medications, please put N/A.*

Pharmacy Name*

Address*

Phone*

Pharmacy Fax*

Medical History:

Have you had any prior surgeries?*

Yes

No

Please list

Have you been seen in the Emergency Room or Inpatient Facility in the past 30 days?*

Yes

No

If Yes where?

Family History Are there any significant medical problems in your family? If yes, please indicate which family member: M = Mother; F = Father; S = Sister; B = Brother; MGM = Maternal Grandmother; PGM = Paternal Grandmother; MGF = Maternal Grandfather; PGF = Paternal Grandfather; O = Other (please specify). If no family history, please put N/A.

Diabetes*

High Blood Pressure *

Alzheimer’s*

Memory Loss*

Dementia *

Anxiety*

Depression*

Psychiatric Problems*

Brain Aneurysm *

Brain Tumor *

Cancer*

Heart Disease*

Balance & Gait Probs *

Migraine *

Dizziness/Vertigo*

Headache*

Multiple Sclerosis*

Muscle Disease *

Neuropathy*

Parkinson’s *

Seizure*

Stroke*

Tremor/Involuntary Movements *

General Review. Please identify any of the following with which you are experiencing any issues.

Heme/Lymphatic*

Abnormal Bruising

Swollen Lymph Nodes

Excessive Bleeding

None

Date*

Are you human?*