Neurology History Form Page 2
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4Physician’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)______________
_____________________________________________________________________
_________________________________________________________________
Page 2 of 4
filename: Neurology Intake form
Last saved by Donna M. Koning 2/25/2009
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