Neurology - San Francisco Date:
REASON FOR TODAY'S VISIT:
Circle OTHER Illnesses you currently have OR have had in the past (include year)
Neurological: stroke - seizure - weakness/numbness in arms/legs - visual blurring - headache
Cardiovascular: high blood pressure - heart attack - irregular heart beat - other heart problem
Respiratory: asthma - emphysema - tb
Hematological: anemia - blood transfusions - bleeding or bruising
Gastrointestinal: ulcers - heartburn - bowel disease - liver disease - constipation or diarrhea
Genitourinary: kidney or bladder problems - difficult or frequent urination - lack of bladder control - prostate problems
Gynecological: pregnancy - menstrual problems
Endocrine: diabetes with Insulin or with pill - thyroid disease - hormone replacement
Musculoskeletal: back pain - neck pain - leg pain - arm pain - joint pain
General: weight loss/gain - difficulty sleeping - snoring
Emotional:
Other (Skin, Eyes, Ears...)
Surgeries: Problem Date Hospital/Doctor
Family History: Age Alive or @ Death Medical Problems in Family Member
Father ______A _______ D
Mother _______A _______D
# Brothers ____ _______A _______D
# Sisters ____ _______A _______D
# Children ____ _______A _______D
Habits: Alcohol: none - social - moderate - excessive - stopped in year: ____ Exercise:
Smoking: none - <1 ppd - >1 ppd - stopped in year: ____
Do you have a Durable Power of Attorney for Health Care? Y N
Current Medications: with dosage Number taken daily
ALLERGIC REACTIONS: Use other side if needed