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Neurosurgery Patient QuestionnaireToday’s Date: __________________________ Name: ________________________________ Date of Birth: _______________________________Age: __________________________________ Right handed/Left handed: ____________________Referring Physician______________________Primary Care Physician: _______________________Chief ComplaintWhat is your main complaint or symptom that brought you to see us: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________What makes it better or worse: __________________________________________________________________________________________________________________________________________________________________________Present IllnessPlease circle if you have any of these problemsHeadacheNauseaVomitingSleepinessSpeech problemsNumbnessWeaknessWalking problemsBladder problemsBowel problemsPainSeizureHearing lossDizzinessTinglingWhat doctors have treated you for this condition:____________________________________________________________________________________________________________________________________________________________Have you had any scans: If so, what kind? CT scan____ MRI____ Other________________________________________Any previous treatments for this condition? If so, please specify:_______________________________________________________________________________________________________________________________________________Review of SystemsCircle if you have any of the followingFeverFatigueWeight LossWeight GainChange in appetiteVisual ChangesSeasonal AllergiesShortness of BreathChest PainAbdominal PainDiarrheaConstipationBloody/Tarry stoolsLoss of LibidoExcessive hunger/thirstDifficulty urinatingEasy BruisingEasy BleedingRash/Skin ConditionMuscle Aches and PainsDepressionMemory problemsSpontaneous Nipple DischargePast Medical HistoryHeart diseaseAsthmaEmphysemaDiabetesThyroid problemsCancerHigh Blood PressureUlcerSerious InjuriesStrokeKidney ProblemsHave you had any surgeries? If yes, please list_______________________________________________________________________________________________________________________________________________________________Do you take any blood thinning medications? If yes, please list_________________________________________________________________________________________________________________________________________________Are you allergic to any medications, latex, or tape? If yes, please list_____________________________________________________________________________________________________________________________________________Family HistoryHave any members of your family had serious illness (such as grandparent, sibling)? If yes, please list and include which family member______________________________________________________________________________________Social History Marital Status: Single____ Married ____What type of work do you do? _________________________________________________________________________Do you use any nicotine containing products? ____________________________________________________________Do you consume alcohol? _____________________________________________________________________________Do you take any illicit drugs? __________________________________________________________________________Sensation Drawing Mark the area on your body where you feel the described sensations. Use the appropriate symbol. Include all affected areasSymptomAcheBurningNumbnessPins & NeedlesStabbingSymbol^^^^xxxx0000////= = = =How bad is your pain? (circle one)On scale of 0 to 10 (0=no pain, 5= moderate, 10 worst pain)At its very worst 0 1 2 3 4 5 6 7 8 9 10Now0 1 2 3 4 5 6 7 8 9 10Current MedicationsPlease list your current medications, vitamins and supplements. Please include the dosage, frequency taken, and prescribing provider. MedicationsDosageFrequencyPrescribing ProviderAdditional Comments: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ................
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