Neurocmi2k502.doc

Copyright S. Hunter 2005

Advanced Neurosciences Institute
CURRENT MEDICAL INFORMATION
Neurology
Instructions: Complete the following information
Last name:
by checking the appropriate box or
First name:
printing information.
Date of Birth:
Please do not write in the areas
Social Security:
labeled “Reviewer’s Comments.”
Current Medical Information
Please write in the box the
problems you are now having:
Today’s date:______________
Age:___
Religion:________
Home Phone: (___)____-_______ Work Phone: (____)____-_______
Do you have a living will, advance directives, or power of attorney for health care? pYes pNo
Did a physician send you? pYes pNo
________________________________
Phone: (___)___-____ ________________________________
I have received a copy of the Privacy Policy and am aware my private health care information
may be available to insurers, government, and family members? pYes pNo
Signature of patient or legal guardian____________________________________
Name of person completing this form (if not patient):_________________________
Relationship:_________
Medications:
Allergies:

Identify current prescription and non-prescription medications. Have you ever had a significant reaction to:
Include any vitamins, supplements, contraceptives, pain
or cold medicines, as well as other remedies): pNo medicines now pSee my attached list
DO NOT WRITE ON REVERSE
Any medication allergy: pNo pYes (list below)
Name of Medication
Dose (mg)
Times per day taken
Medication Allergy
Describe reaction or allergy
Other recent medications:____________________________________________________________________
________________________________________________________________________________________
Have you taken cortisone, prednisone, or “steroid” type drugs in the last year? pNo pYes When?________
Have you taken aspirin or aspirin-containing medicines in the last two weeks? pNo pYes When?________
Are there medications “other than Allergies” which had unpleasant side effects?______________________
_______________________________________________________________________________________
New Medical and Social Information
This is my first visit to this clinic: pYes pNo If “No”, please answer the following: Last Visit:______________
Any new or worse medical problems since your last visit:___________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Have you seen other doctors since your last visit? pNo pYes Whom, When and Why?___________
_________________________________________________________________________________
_________________________________________________________________________________
Have you started new medications since your last visit? pNo pYes Which ones and why?________
_________________________________________________________________________________
Have you had any significant events in your life since your last visit? pNo pYes
What & When?_____________________________________________________________________
Copyright 2005 S. Hunter

Advanced Neurosciences Institute
CURRENT MEDICAL INFORMATION
Neurology
Instructions: Complete the following information
Last name:
by checking the appropriate box or
First name:
printing information.
Date of Birth:
Please do not write in the areas
Social Security:
labeled “Reviewer’s Comments.”
Review of Systems
to the following as related to your current visit.
Have you had (please check item):
Reviewer’s Comments
Any reactions to pfoods, pmolds, pdust or pbee stings? A pfever, psore tongue, or pmouth sores in the last month? A change in weight pup/pdown more than 10 lbs. in the last 6 mos? Any penlarged glands, pgoiter or plymph nodes: pblood clotting disorder, frequent bleeding pgums/pnose or pbruising? A pskin rash, psores, pbreast lumps or pchanging moles? Noticed a recent change in your pskin or phair texture? Great difficulty with feeling phot/pcold when others are comfortable? Excessive purination and pthirst? When?_____________________
A problem with pdisabling pain or pfatigue? Where?_____________
pPain or pstiffness in your pjoints (which:_______________) or pback? p pDouble vision or pblurred vision? pGlasses? pLazy or crossed eye? Problems with pfalling/pstaying asleep or being ptoo sleepy? pSevere/pfrequent headaches? pFunny sensations or pnumbness? pFainting, pfalling, other punusual spells, pseizures, or pconvulsions? p Difficulty with pslurred speech or pweak/pclumsy parm/pleg? pTremors, pjerks, pcramps, or pother abnormal movements? Marked difficulty with pmemory, pconfusion, or pexpressing yourself? Feel pstressed, pdepressed, ptired, or pnervous frequently? Problem phearing, pdizziness, phoarseness or with psinuses? Difficulty peating, pdrinking, pchewing, pchoking or pswallowing? Chest ppain/ppressure, abnormal pheart beat, pvalve, or pmurmur? Shortness of breath pat night or pwith only a little activity? Abnormal swelling of your pankles or pfeet? pCalf pain when walking? pAsthma, pwheezing, or pcoughing up psputum or pblood? pIndigestion, pheartburn, pnausea, pvomiting, or pstomach ulcers? pConstipation, pdiarrhea, or pblood/pchanges in bowel movements? pBurning or ppain when urinating or pbloody urine? Difficulty with pstarting urine, pemptying bladder, or pleaking urine? Women only:
A pmammogram, pPap smear, and ppelvic examination in the last year? p pirregular menstrual periods or precent abnormal vaginal discharge?
Health Care Provider Review - I have reviewed this form with the patient:
._______________________________________________________
________________________________________________ _______________________________________________________ ________________________________________________

Source: http://www.neurosci.us/images/NeuroCMI2k502.pdf