Patient Name: ________________________________ Date of Birth: _______________ Date: _______________
Please list all current diagnoses and chronic conditions. This helps your neurologist understand how your other health conditions may relate to your neurological symptoms.
Current Diagnoses
Diagnosis / Condition
Year Diagnosed
Treating Physician
Current Status
Active Resolved
Active Resolved
Active Resolved
Active Resolved
Active Resolved
Active Resolved
Active Resolved
Active Resolved
Cardiovascular Risk Factors
High Blood Pressure High Cholesterol Diabetes / Pre-diabetes Atrial Fibrillation Heart Attack Heart Failure Peripheral Artery Disease Obesity (BMI > 30) Smoking Family history of stroke
Neurological Conditions
Epilepsy / Seizures Migraine Parkinson's Disease Multiple Sclerosis Alzheimer's / Dementia Neuropathy Stroke / TIA Brain Tumor Spinal Cord Injury ALS / Motor Neuron Disease Myasthenia Gravis Muscular Dystrophy