Neurology History Form printable pdf download

Neurology History Form

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

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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?

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:_____________________________________

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filename: Neurology Intake form

Last saved by Donna M. Koning 2/25/2009

Neurology History Form