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Patient name:Date of birth:Age:Right-handed:Left-handed:Ambidextrous:Reason for visit: Occupation:Previous Occupation:Spouse’s occupation:Primary Care Provider: Hobbies:What pharmacy do you use? CURRENT MEDICATIONInclude dosage/frequencyMedicationDosageFrequency Allergy Reaction Allergy ReactionSURGICAL HISTORY(continue on back of form, if more space is needed)Date:Type of Surgery:Date:Type of Surgery:Date:Type of Surgery:HOSPITALIZATIONSDate:Reason for Hospitalization:Date:Reason for Hospitalization:Date:Reason for Hospitalization:Family History:MotherFatherSisterBrotherDaughterSonDiabetesHypertensionStrokeHeart attackMental IllnessCancerHealthyUnknownDeceasedHow many? Sisters: Brothers: Sons: Daughters:Adopted? Yes No Family history unknown? Yes NoCircle Current and past illnesses:AIDS/HIVDiabetesLiver DiseaseVascular DiseaseAnemia/Blood disorderGastritis/GERDLung Disease/COPDHard of hearingAnxiety/Panic attacksHead injuryMajor Vehicle accidentVision ConcernArthritisHeart attack/Heart diseaseStrokeHeadaches / MigrainesCancerHigh CholesterolseizuresTremorCarpal Tunnel Kidney StonesSleep apneaOther:DepressionKidney DiseaseSubstance abuseAre you currently having problems with any of the following? Yes NoArm weaknessLeftRightBothLeg weaknessLeftRightBothArm numbnessLeftRightBothLeg numbnessLeft RightBothArm painLeft RightBothLeg painLeftRightBothSocial History:Do you smoke?CurrentFormerNeverHow often?EverydaySomedaysHow many cigarettes in a day?11-20 per day6-10 per day5 or less per dayHow soon after waking up?Within 5 minutes6-30 minutes30 minutes or longerHow long have you been smoking for?Interested in quitting?Ready to quitThinking about itNot ready to quitChew tobacco?CurrentFormerNeverDo you Vape?Cartridges per day:Nicotine Strength:How long?Drink Alcohol?Frequency:Amount:Type:Currently sexually active?MalesFemalesBothExercise?Frequency:Caffeine?YesNoFrequency?Amount?Travel outside US?Location?Are you currently having problems with any of the following? (Circle)Slurred SpeechRinging in ears or hearing loss?LeftRightbothWeight loss or gainMemory ProblemBladder or Bowel incontinenceInability to smell or tasteLeg pain while walking?LeftRightBothExcessive thirstChanges in appetiteBlurred VisionHeadachesRestless LegsDouble visionShortness of breathWalking ProblemsFacial PainFever/ Night sweatsBack painNausea or vomitingIrregular pulseChest painSwelling of hands or feetJoint painOther:Social History (continued):Have you had any type of occupational exposure?YesNoWhat kind?Smoke detector in house?YesNoCarbon Monoxide Detector?YesNoDo you have pets?YesNoWhat type?Do you feel safe at home?YesNoYes, I am at risk for HIV/AIDS due to sexual orientation, drug abuse, or previous blood transfusions. Yes, I have used drugs such as methamphetamine, marijuana, cocaine, heroin, LSD or PCP.I have carefully reviewed this questionnaire and completed it to the best of my knowledge. _________________________________________________________________Signature of: Patient, parent, legal guardian (circle one)Date/Time ................
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