MICHIGAN STATE UNIVERSITY DEPARTMENT OF NEUROLOGY AND ...

MICHIGAN STATE UNIVERSITY DEPARTMENT OF NEUROLOGY AND OPHTHALMOLOGY GENERAL NEUROLOGY SERVICES PATIENT QUESTIONNAIRE.

Name: City: Home Phone: Cell Phone:

Right Handed

Date of Birth:

Left Handed

Age:

Address: State: Work Phone: Email Address: Sex: Place of Birth:

ZIP: Social Security:

Referring Physician:

Primary Care Physician:

Address:

Address:

City:

State:

ZIP:

City:

State:

ZIP:

Phone Number:

Phone Number:

Please list the physicians, other than your primary care and referring physicians, who you would like to receive a report from our office:

PHYSICIAN NAME:

ADDRESS:

TELEPHONE:

Please list the chief complaints that brought you to our office today:

Current Weight:

Current Height: Page 1 of 6

Patient Name:

Please LIST ALL MEDICATIONS you are currently taking. This should include patches, eye drops, aspirin, birth control pills and nonprescription drugs such as vitamins or herbs. (Attach a separate list if necessary or bring complete list with you to your appointment)

MEDICATION

DOSE/FREQUENCY YEARS TAKEN

REASON PRESCRIBED

ALLERGIES TO MEDICATIONS / PROCEDURES?

NO

YES If yes, please list medication and reaction:

PAST MEDICAL HISTORY (Please include approximate dates).

Anxiety/Depression:

Diabetes:

Asthma:

Head Injury/trauma:

Atrial fibrillation: Autoimmune disorder: Brain tumor:

Cancer:

Depression:

Heart attack:

Heart disease:

High cholesterol: High blood pressure: Liver disease:

Dementia:

Meningitis:

Others:

Page 2 of 6

Migraine: Peripheral neuropathy: Peripheral vascular disease: Polycystic kidney disease: Renal failure: Seizure disorder: Stroke: Thyroid disease:

Patient Name:

Please list type of surgery, including eye surgery (or laser surgery), and approximate dates:

How often do you exercise?

Are you on a special diet?

Yes

No

If yes, explain:

FAMILY MEDICAL HISTORY: (Please indicate if any immediate family members have the illness)

Alzheimer's:

Depression

Balance problems

Diabetes

Cancer

Coronary artery disease < age 55

Huntington's disease

Bleeding disorder

High Cholesterol High blood pressure (Hypertension)

Migraine

Multiple sclerosis

Please provide any additional details below:

Muscular Dystrophy

Myasthenia gravis

Heart Attack

Polycystic kidney disease

Renal failure Schizophrenia Stroke Stroke ................
................

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