Neurosurgical Patient Registration Form

Patient Information

• Full Name: _________________ Date: _________________
• Date of Birth: _____________ Age: _____ Gender: _____
• Address: ________________________________________________
• Phone: (Home) _____________ (Mobile) _____________
• Email: ________________________________________________
• Emergency Contact: _____________ Phone: _____________

Insurance Information

• Primary Insurance: _________________ ID#: _____________
• Secondary Insurance: _______________ ID#: _____________

Medical History

Current Symptoms

• Primary Complaint: ____________________________________
• Duration of Symptoms: _________________________________
• Pain Level (0-10): ____________________________________
• Location of Pain/Symptoms: ____________________________

Previous Treatments

• Previous Surgeries: □ Yes □ No If yes, please list: ___________________________________
• Current Medications: _________________________________
• Allergies: __________________________________________

Diagnostic Studies

• Recent Imaging: □ MRI □ CT □ X-Ray □ Other
• Date and Location: ___________________________________

Medical Conditions

Please check all that apply: □ Hypertension □ Diabetes □ Heart Disease □ Stroke □ Blood Clotting Disorders □ Seizures □ Cancer

Authorization

I certify that the above information is accurate and complete:

Signature: _________________ Date: _________________