Comprehensive Neurosurgical Medical History Form

Patient Information

• Full Name: _________________ Date: _________________
• Date of Birth: ______________ Age: __________________
• Primary Care Physician: ______________________________
• Referring Physician: ________________________________

Chief Complaint

• Primary reason for visit: ____________________________
• Duration of symptoms: ______________________________

Current Symptoms

Please check all that apply:

• Headache
• Neck pain
• Back pain
• Numbness/Tingling
• Weakness
• Balance problems
• Vision changes
• Seizures
• Memory issues

Pain Assessment

• Location: _________________________________________
• Intensity (0-10): ___________________________________
• Character (sharp/dull/burning): ______________________

Past Medical History

Medical Conditions

• Hypertension
• Diabetes
• Heart Disease
• Stroke
• Cancer
• Other: ___________________________________________

Previous Surgeries

1. Type: _________________ Date: _________________
2. Type: _________________ Date: _________________
3. Type: _________________ Date: _________________

Medications

Allergies

• Medications: ______________________________________
• Contrast dye: [ ] Yes [ ] No
• Latex: [ ] Yes [ ] No

Family History

Please indicate any neurological conditions in blood relatives:

Social History

• Tobacco use: [ ] Never [ ] Current [ ] Former
• Alcohol use: [ ] Never [ ] Occasional [ ] Regular
• Occupation: ______________________________________

Review of Systems

Neurological

• Headaches
• Dizziness
• Speech problems
• Memory loss

Constitutional

• Fever
• Weight loss
• Fatigue

Imaging Studies

Have you had any of the following?

• MRI Date: ____________
• CT Scan Date: ____________
• X-rays Date: ____________

Authorization

I certify that the above information is accurate to the best of my knowledge.

Signature: _________________ Date: _________________