Physical Examination & Review of Systems
Patient Name: ________________________________ Date of Birth: _______________ Date: _______________
Neurological Review of Systems
Check any symptoms you are currently experiencing or have experienced in the past 6 months:
Headaches
Dizziness / Vertigo
Fainting / Blackouts
Seizures / Convulsions
Memory Loss
Confusion
Difficulty Speaking
Difficulty Swallowing
Vision Changes
Double Vision
Hearing Loss / Tinnitus
Facial Numbness / Pain
Weakness (arm/leg)
Numbness / Tingling
Tremors / Shaking
Balance Problems
Difficulty Walking
Falls
Muscle Cramps / Spasms
Sleep Problems
Mood Changes
Fatigue
General Review of Systems
| System | Symptoms (check if present) | Notes |
|---|
| Cardiovascular | Chest pain Palpitations Shortness of breath | |
| Respiratory | Cough Wheezing Shortness of breath | |
| Gastrointestinal | Nausea Vomiting Constipation Diarrhea | |
| Musculoskeletal | Joint pain Muscle weakness Back pain | |
| Psychiatric | Depression Anxiety Hallucinations | |
| Endocrine | Weight change Heat/cold intolerance Excessive thirst | |
Current Physical Limitations
Describe any activities you are currently unable to perform or have difficulty with due to your condition:
Functional Status
None
Cane
Walker
Wheelchair
Hearing Aid
Other: _______________
Yes
No — with: _______________
Yes — Name: _______________
No
Additional Notes
Use this space for any additional information you feel is important for your neurologist to know.