Patient History Form

Please complete all sections. Use additional paper if needed. Date: ___________________

This information is confidential and protected under HIPAA. It will only be used to provide you with the best possible neurological care.

Patient Information

Last Name

First Name

Middle Initial

Date of Birth (MM/DD/YYYY)

Age

Sex at Birth

Address

City

State

ZIP

Home Phone

Cell Phone

Email Address

Emergency Contact Name

Relationship

Emergency Phone

Primary Care Physician

Referring Physician

Insurance Provider

Past Medical History

Check all that apply:

Hypertension Diabetes Heart Disease Stroke / TIA Cancer Thyroid Disease Kidney Disease Liver Disease Autoimmune Disease Depression / Anxiety Sleep Apnea Migraines Epilepsy / Seizures Multiple Sclerosis Parkinson's Disease Other (describe below)

Other conditions not listed above

Surgical History

Year	Procedure / Surgery	Hospital / Facility	Surgeon

Hospitalizations

Year	Reason for Hospitalization	Hospital	Duration

Family History

Check conditions present in blood relatives and note relationship (e.g., Mother, Father, Sibling):

Condition	Relative	Condition	Relative
Stroke / TIA		Epilepsy / Seizures
Parkinson's Disease		Alzheimer's / Dementia
Multiple Sclerosis		Migraines
Heart Disease		Diabetes
Cancer		Other Neurological

Social History

Occupation

Marital Status

Highest Education Level

Tobacco Use

Never Former (quit: ______) Current (packs/day: ______)

Alcohol Use

None Occasional Moderate (drinks/week: ______) Heavy

Recreational Drug Use

None Past (describe: ______________________) Current (describe: ______________________)