Chief Complaint & Symptom History

Patient Name: ________________________________ Date of Birth: _______________ Date: _______________

Please describe your main concern in as much detail as possible. The more specific you are, the better your neurologist can prepare for your visit.

Primary Complaint

What is the main reason for your visit today? (Describe in your own words)

When did this symptom first begin? (Date or approximate)

How did it start?

Has the symptom changed over time?

Getting worse Getting better Staying the same Comes and goes

How often does it occur?

Constant Daily Weekly Monthly Episodic

How long does each episode last?

Time of day when worst?

Location of symptom (where on your body?)

Does it spread or radiate anywhere?

Severity (circle): 1 2 3 4 5 6 7 8 9 10

(1 = barely noticeable, 10 = worst imaginable)

Quality / Character of symptom

Sharp Dull Throbbing Burning Pressure Tingling Numbness Weakness

What makes the symptom WORSE?

What makes the symptom BETTER?

Associated symptoms (other things that happen at the same time?)

How has this symptom affected your daily activities, work, or quality of life?

Have you seen another doctor for this problem?

Yes — Doctor: _______________________ No

What tests have been done? (MRI, CT, EEG, blood work, etc.)

What treatments have been tried? (medications, therapy, procedures?)

What was the result of those treatments?

What are you hoping to achieve from this visit?