Comprehensive Neurological Medical History Form

Patient Information

• Full Name: _________________ Date of Birth: _________________
• Date: _________________ Medical Record #: _________________

Chief Complaint

• Primary reason for visit: _________________
• Duration of symptoms: _________________

Neurological Symptoms (check all that apply)

• Headaches
• Dizziness/Vertigo
• Seizures
• Memory problems
• Balance issues
• Tremors
• Weakness
• Numbness/Tingling
• Vision changes
• Speech difficulties

Pain Assessment

• Location: _________________
• Severity (1-10): _________________
• Character: □ Sharp □ Dull □ Throbbing □ Burning
• Frequency: □ Constant □ Intermittent □ Occasional

Past Medical History

Neurological Conditions

• Stroke/TIA
• Epilepsy
• Multiple Sclerosis
• Parkinson's Disease
• Migraine
• Other: _________________

Other Medical Conditions

• List: _________________

Family History

• Neurological conditions: _________________
• Other relevant conditions: _________________

Medications

• Current medications: _________________
• Allergies: _________________

Social History

• Occupation: _________________
• Tobacco use: □ Yes □ No
• Alcohol use: □ Yes □ No
• Other substances: _________________

Review of Systems

Constitutional

• Fatigue
• Weight changes
• Sleep problems

Neurological

• Cognitive changes
• Coordination problems
• Gait disturbance

Previous Testing

• MRI/CT scans: _________________
• EEG: _________________
• EMG/NCV: _________________

Additional Notes

Patient Signature: _________________ Date: _________________ Provider Signature: _________________ Date: _________________