HIGHLAND SLEEP DISORDERS & NEUROLOGY, Inc.
NAME:______AGE:______
LAST FIRST MIDDLE
REASON FOR CONSULTATION: ______
NAME OF PHYSICIAN WHO REFERRED YOU: ______
YOUR FAMILY PHYSICIAN: (ONE WHO USUALLY GIVES PHYSICALS, REGULAR CARE, ETC): ______
OTHER PHYSICIANS YOU ARE CURRENTLY SEEING: ______
HANDEDNESS (THE HAND YOU WRITE WITH, ETC) : RIGHT O LEFT O EVENHANDED O
CC: (EXPLAIN FURTHER WHY YOU ARE HERE TODAY)LIST ALL PROBLEMS FOR WHICH YOU ARE NOW SEEING A DOCTOR:
______
LIST ALL SURGERY (including any done during childhood – i.e. appendectomy, tonsillectomy, etc.):
PROCEDURE DATE SURGEON
______
______
______
______
______
______
______
LIST BROKEN BONES, ACCIDENTS, MOTOR VEHICLE ACCIDENTS:
DATE PART OF BODY INVOLVED
______
______
______
______
______
______
LIST ALL MEDICATIONS: (USE ANOTHER SHEET OF PAPER IF NEEDED FOR ADDITIONAL SPACE)
NAME STRENGTH PER PILL FREQUENCY OF ADMINISTRATION______EXAMPLE: TEGRETOL 250 MG ONE PILL AT LUNCH, DINNER AND TWO AT BEDTIME
______
______
______
______
______
______
______
______
______
______
______
______
______
______
LIST ANY ALLERGIES TO MEDICATIONS AND/OR OTHER THINGS (example: POLLEN, CERTAIN FOODS, ETC.)
____________
FAMILY HISTORY:PLEASE LIST ANY FAMILY HISTORY INCLUDING YOUR RELATIVES THAT HAVE HIGH BLOOD PRESSURE, DIABETES, HISTORY OF CANCER, ETC.
______
______
______
Personal History:
Tobacco: How much:
Alcohol: How much:
Street Drugs:
Married Divorced Single Separated WidowedHow many children:
______
FOR EACH OF THE FOLLOWING PLEASE CHECK THE PROPER BOX. IF YOU CHECK A BOX, PLEASE WRITE BESIDE THE SYMPTOM THE DATE WHEN YOU HAD THE SYMPTOM.
PAST / SYMPTOM / PRESENT0 / DIZZINESS, VERTIGO, POOR BALANCE, COORDINATION, CLUMSINESS / 0
0 / STROKE / 0
0 / DIABETES (SUGAR IN BLOOD) / 0
0 / SKIN PROBLEMS OR DISORDER / 0
0 / SEVERE HEADACHES / 0
0 / MUSCLE ACHES OR CRAMPS / 0
0 / CONFUSION, MEMORY, CONCENTRATION / 0
0 / PERSONALITY CHANGE / 0
0 / SPEECH DIFFICULTY / 0
0 / BLURRED VISION, BRIEF LOSS OF VISION OR DOUBLE VISION / 0
0 / DECREASED HEARING (WHICH EAR?) / 0
0 / HOARSENESS / 0
0 / NUMBNESS, TINGLING (WHERE?) / 0
0 / DEPRESSION / 0
0 / WEAKNESS OR PARALYSIS / 0
0 / VARICOSE VEINS / 0
0 / HEART PROBLEMS / 0
0 / GYNECOLOGICAL PROBLEMS (FEMALE) / 0
0 / PROSTATE PROBLEMS (MALE) / 0
0 / TROUBLE WALKING / 0
0 / NO CONTROL OF BOWELS (WET OR LOSE CONTROL OF BOWELS OR BLADDER / 0
0 / SNORING / 0
0 / SEIZURES, CONVULSIONS, BLACKOUT SPELLS, FAINTING / 0
0 / LETHARGY, SLEEPINESS, SLUGGISHNESS, FATIGUE / 0
0 / HALLUCINATIONS / 0
0 / PROBLEMS WITH SMELL / 0
0 / CHEWING PROBLEMS / 0
0 / TROUBLE SWALLOWING / 0
0 / CHOKING / 0
0 / EAR/NOSE/THROAT PROBLEMS / 0
0 / GASTROINTESTINAL (STOMACH AND/OR INTESTINES) PROBLEMS / 0
0 / STIFFNESS, PAIN, ARTHRITIS / 0
0 / PROBLEMS WITH SLEEPING IN GENERAL / 0
0 / EYE INFECTIONS / 0
0 / GLAUCOMA / 0
0 / RINGING IN EARS / 0
0 / SINUSITIS / 0
0 / HAY FEVER / 0
0 / SHORTNESS OF BREATH / 0
0 / TUBERCULOSIS / 0
0 / PNEUMONIA / 0
0 / CHRONIC COUGH / 0
0 / CHEST PAIN / 0
0 / PALPITATIONS / 0
0 / HEARTBURN / 0
0 / CONSTIPATION / 0
0 / STOMACH ULCERS / 0
0 / COLITIS / 0
0 / JAUNDICE / 0
0 / HEMORRHOIDS OR RECTAL DISEASE / 0
0 / KIDNEY DISEASE / 0
0 / BLADDER INFECTIONS / 0
0 / GONARRHEA OR SYPHILIS / 0
0 / IMPOTENCE / 0
0 / MENOPAUSE / 0
0 / HEAD INJURY / 0
0 / BLEEDING DISORDER OR ANEMIA / 0
0 / BACK PAIN / 0
USE THE SPACE BELOW TO LIST ANY OTHER ILLNESS or SYMPYOM NOT COVERED ABOVE
______
LIST ANY UNUSUAL CHILDHOOD DISEASES:
______
____________