Neurology History Form (Page 4 of 4) in pdf

SOCIAL HISTORY:

Physician’s Notes

Are you

___single

___married

____partnered

___divorced

___widowed

If applicable, how many years have you been or were you married?____________________

Please

Number of children and ages:______________________________________________

do not

What is your occupation? ________________________________________

Education: list highest grade/degree attended:_______________________________

write

Have you ever smoked or chewed?__yes ___no What age did you start?______

Do you currently smoke or chew? ____no, I quit (date) ____.

___yes How much per day?______

How much alcohol do you drink per week?__________________________________

this

Have you ever used street drugs or drugs not prescribed to you?______________________

space

What are your significant hobbies or interests?_________________________

REVIEW OF SYSTEMS: Please circle problems you have now or had recently

Neurological: Memory loss, word finding problems, getting lost frequently,

difficulty doing tasks you could do previously, seizures, loss of consciousness,

loss of sense of smell, double vision, dizziness, tinnitus or ringing in your ears,

problems with hearing, slurred speech, problems chewing or swallowing,

change in sense of taste, weakness in part of your body, numbness, incoordination, falls, loss

of balance, pain or tingling, difficulty walking, muscle stiffness, muscle cramps, tremor,

problems controlling movement, muscle jerks or twitches

Ocular: decreased vision, double vision, pain in eyes.

Autonomic: dry eyes, dry mouth; any of these changes when you stand up: dizziness,

weakness, fatigue, mental changes, visaual changes, vertigo, anxiety, heart palpitations,

nausea, fainting

All of these

systems

Blood disorders: anemia, bruising, bleeding gums, recurrent infections, etc.

reviewed, and

Heart: heart attacks, chest pain, shortness of breath, swollen feet, light-headedness,

unless circled

palpitations, atrial fibrillation, etc.

are negative or

noncontributory

Lungs: shortness of breath, spitting up blood, painful breathing, increased phlegm.

Gastrointestinal: any of these changes after eating: early fullness, bloating, nausea,

dizziness, sweating.

Any time: abdominal pain, vomiting blood, dark/tarry bowel movements, heartburn, diarrhea,

constipation;

Urinary / kidneys: incomplete emptying of your bladder, difficulty starting the stream,

losing urine (icontinence), being unable to gopainful urination, blood in urine, pus in urine,

previous history of bladder disease, kidney disease.

Sexual: inability to get an erection, difficulty achieving orgasm, retrograde ejaculation

(painful ejaculation back into the bladder)

Endocrine: diabetes, thyroid disease, B12 deficiency, adrenal insufficiency,

hypertension, problems with calcium metabolism, pituitary problems, excessive thirst,

Skin: rashes, sores, unusual spots or patches of color, skin cancer, melanoma, new lumps or

bumps, changes in skin appearance that come and go

Musculoskeletal: joint pain, muscle pain, joint deformities, frequent fractures, arthritis

Allergic/Immune: allergies, hay fever, sinus problems, frequent infections

Ears, nose, throat: sinus disease, decreased hearing, vertigo, ringing in ears, sores in mouth,

nasal polyps

Psychiatric: anxiety, depression, hallucinations, violent behavior

Constitutional: unexplained weight gain or loss, fever, chills, fatigue, sweats,

Page 4 of 4

filename: Neurology Intake form

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

Neurology History Form Page 4

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