Medical History Form
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1
2MEDICAL HISTORY
Today's Date ___/___/___
Birthdate____/____/____
Age________
NAME:_____________________________________________
Reason for Neurological Evaluation:
q Right-handed
q Left-handed
q Ambidextrous
Are You:
MEDICATIONS: Please list current medications including prescription and non-prescription (over the counter)
drugs, vitamins, supplements, etc. Include the milligram dosage and how often you take them.
PLEASE CHECK ANY OF THE FOLLOWING CONDITIONS YOU HAVE OR HAVE HAD IN THE PAST:
q TIA
q High Blood Pressure
q Kidney Disease
q Stroke
q Diabetes
q Kidney Stones
q Seizures
q High Cholesterol
q Thyroid Disease
q Epilepsy
q Heart Attack
q Lupus
q Migraine
q Atrial Fibrillation
q Arthritis
q Dementia
q Heart Failure
q Lyme Disease
q Alzheimer's Disease
q Heart Valve Disease
q Cancer
q Parkinson's Disease
q Fainting
Type
q Multiple Sclerosis
q Pacemaker/Defibrillator
q Glaucoma
q Brain Tumor
q Asthma
q Anxiety
q Spinal Tumor
q Emphysema
q Depression
q Meningitis
q Stomach Ulcers/GERD
q Psychosis
q Encephalitis
q Liver Disease
q Alcoholism
q Concussion
q Pregnancies/deliveries
q Drug Abuse
q Brain Injury
q Syphilis
q AIDS/HIV
q Spine Injury
q Miscarriage
q Tuberculosis
q Sleep Apnea
PLEASE LIST ANY OTHER MEDICAL CONDITIONS NOT LISTED ABOVE:
ALLERGIES:
Please list all medications that have caused you to have an allergic reaction or other serious side-
effect. List name of drug and brief description of reaction.
Revised 4/3/13
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Reviewed with Patient by:_________
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Parent category: Medical