PATIENT MEDICAL HISTORY
NAME: AGE: ___ DATE: ______
HEIGHT: WEIGHT: RIGHT-HANDED _____ LEFT-HANDED ______MIXED
Chief Complaint: ______
(reason you are here today)
Location ______Quality ______
(where is the pain/problem?) (Example: normal vs. abnormal, color, activity, etc)
Severity ______Duration ______
(how severe is the pain/problem on a scale of 1-5?, 5 being the most severe) (how long have you had this pain/problem, when did it start?)
Timing ______Context ______
(does this pain/problem occur at a specific time?) (where were you at the onset of pain/problem?)
Associated signs/symptoms ______Modifying factors ______
______
(what other associated problems have you been having?) (what makes the pain/problem worse or better? Have you had this before?)
Past Medical History
Dementia/Memory Loss ______Difficulty Walking/Balance Problems __
______
Epilepsy/Seizures ______
Headache/Migraine ______
Multiple Sclerosis ______
Myasthenia Gravis ______
Neuropathy ______
Nerve Injury ______
Parkinson’s Disease ______
Stroke ______
Torticollis ______
Tremor ______
Vertigo ______
Arthritis ______
Asthma ______
Alcoholism/Drug Dependence ______
Blood Transfusion ______Cancer (please specify) ______
______
Cholesterol ______
Diabetes ______
Heart Problem:
Heart Attack ______
Heart Failure ______
Atrial Fibrillation ______
Pacemaker/Defibrillator ______
Injury to Back ______
Injury to Head ______
Injury to Limb ______
Injury to Neck ______
Kidney Disease (please specify) ______
Obesity ______
Sleep Apnea ______
Sleep Disorder ______
Thyroid Disease ______
Urinary Incontinence/Frequency ______
______
PAST SURGERY:
______
______
______
______
______
ALLERGIES: ______
______
Prescription Medications: ______
Over the Counter Medications: ______
FAMILY HISTORY: (PLEASE FILL IN ALL BOXES THAT APPLY.)
LIVING(AGE) / SIGNIFICANT ILLNESS? / DECEASED (AGE) / CAUSE OF DEATH
FATHER:
MOTHER:
SIBLING(S)
CHILDREN
Social History
Occupation:______When retired ______
Who lives with you______Marital status ______Number of children ___
Hobbies/interests ______Military history ______
Education ______Tobacco ______Packs per day ______Years ______Quit ______
Recreational drugs ______Exercise ______How much per week ______
Caffeine amount per day ______Do you drive______Accidents ______Alcohol/Wk ______
Hours of sleep ______other details I should know: ______
For MS patients only
Year of diagnosis ______First symptoms ______
Current treatment since when ______Failed treatments (and why) ______
Last MRI ______Last exacerbation ______
Current symptoms ______
Prior Neurologist ______
For head pain patients only
Headache types and frequency: ______
How often does your head hurt? ______Is there a warning? ______
How long does the head pain last? ______What medicine do you take for the attack? ______
Circle which describes the pain: throbbing pounding steady severe sharp disabling wakes you up light sensitive
Is it better with rest or movement? ______Is it better with lying down or standing? ______Is it better in the
am, pm or neither ______What medication did you take for prevention? ______
If there are different types of pain, please list types and what works to stop it ______
Prior neurologist ______
For Parkinson's patients only
Year of diagnosis ______Medications that failed to help ______
Circle any you have had: hallucinations, daytime sleepiness, sleep problems, constipation, falling, confusion,
tremor/abnormal movements, lightheadedness, vivid dreams or nightmares
Circle any you have had: trouble driving, getting lost,bladder problems,tremor,slowness,stiffness
Prior neurologist ______
Signature of Patient Date Signed______