Neurology History Form Page 3
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2
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4Physician 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
Page 3 of 4
filename: Neurology Intake form
Last saved by Donna M. Koning 2/25/2009
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