Before Your Visit

Patient Intake Forms

Please download, print, and complete these forms before your appointment. Bringing completed forms saves time and helps your neurologist prepare for your visit.

Download each form below, print it out, fill it in completely, and bring it to your appointment. If you have questions about any section, our staff is happy to help — call us at (555) 000-0000.

Patient History Form

2 pages

Comprehensive medical history including past illnesses, surgeries, hospitalizations, family history, and social history.

Download Form

Physical Examination & Review of Systems

2 pages

Review of body systems and any current physical limitations or functional concerns relevant to your neurological care.

Download Form

Current Medications & Drug Allergies

1 page

List all current prescription medications, over-the-counter drugs, supplements, and any known drug allergies or adverse reactions.

Download Form

Comorbid Conditions

1 page

Documentation of existing diagnoses and chronic conditions that may be relevant to your neurological evaluation.

Download Form

Chief Complaint & Symptom History

1 page

Describe your primary concern, when symptoms began, how they have changed over time, and what makes them better or worse.

Download Form

Also Required

Upload Your ID & Insurance Card

In addition to these forms, please upload a photo of your driver's license and both sides of your insurance card before your visit.

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Need Help?

If you are unable to print or complete the forms at home, please arrive 30 minutes early and our front desk staff will assist you.

Call 970-297-8120