Patient Name: Welcome to Cerebrum Health Centers. Carefully complete all of the following health history questionnaires. The accuracy of your answers will help us better diagnose and treat your condition. Thank you for your patience with what may appear to be some duplication in questions in different areas. Each questionnaire has been carefully designed to identify your specific condition. Patient Name: DOB: Patient Guardian/Representative: _ How old are you Handed: Right Left Ambidextrous Male Street Address: Unit/Apt. City: State: ZIP: Phone: ( ) Home Mobile Alternate phone: ( ) E-mail address: Preferred: Cell Home Text Email Emergency Contact Information: Contact Name: Phone: ( ) Home Mobile Alternate phone: ( ) Relationship to Patient: Insurance Information: **Please Note** We do not bill insurance for any treatment in our facility. This information is exclusively for lab and Rx ordering (if necessary). Primary Insurance: Insurance cert #: Plan Type: Group #: Guarantor/Member s _ Guarantor SSN: - - Guarantor s relationship to patient: Husband Wife Parent Primary Pharmacy: Street address: _ City: State: ZIP: Primary Mental Health Provider: Street address: City: State: ZIP: Primary Physician: Street address: _ City: State: ZIP: How did you hear about us? Did a physician refer you? Yes No Physician Name: Physician Address: City: State: ZIP: Telephone Number: ( ) Patient Medical History Page 1 of 8
Patient Name: Check as many that apply to you about your reason for visiting us today: Headaches Sports improvement Sleeplessness Balance issues Head injury Nutritional counseling Neurological assessment Other: If injury occurred, when? / / Another type of accident, trauma, or injury Neurological problem or disease: (Please explain & include any prior diagnoses) Diagnostics: (Please list previous diagnostic tests given for current complaints) CAUSES OF YOUR PAIN SYMPTOMS Event(s) surrounding the onset of symptoms Date Pain Intensity Today Medication List Patient taking nonmedications regularly and none in the past 72 hours MEDICATIONS (INCLUDE OVER-THE-COUNTER AND HERBAL MEDICATIONS) DOSE (e.g., strength, # of pills or drops) ROUTE (e.g., by mouth, # inhaled, on skin) FREQUENCY (how often) Example: Vitamin C 250 mg By mouth Once a day 1. 2. 3. 4. 5. 6. 7. 8. Patient Medical History Page 2 of 8
Patient Name: On the diagram, please mark the following symptoms, if you are experiencing them: // B D A N T St Sw C W Tr stabbing pain for burning pain for dull pain for aching pain on or in areas where you have numbness in areas where you have tingling in areas where you ve had swelling In areas where you have cramps for weakness for tremor Personal Health History Please answer the following questions as completely as possible. Do you have a: Pacemaker Stent List all operations and surgeries you may have had, with dates (month/year) List any major illness you have had, with dates (month/year) Patient Medical History Page 3 of 8
Patient Name: Have you ever been diagnosed with a tumor, cancer, or neoplasia? Have you ever been diagnosed with diabetes? Have you ever been diagnosed with a cardiac (heart) condition, a blood vessel condition (like arteriosclerosis, atherosclerosis, or vasculitis), or hypertension (high blood pressure)? Have you ever had a stroke or heart attack? Have you ever had a spinal cord injury? Have you ever had surgury on your neck? Does anyone in your biological family (parent, grandparent, sibling, or child) have a history of: Heart disease, stroke, cancer or diabetes? Psychiatric diseases like depression, anxiety, schizophrenia, etc? Neuropathies (nerve disease) or myopathies (muscle disease)? Cancer? Back or neck pain? Any other known conditions? Review of Systems & Medical History 1. Does anything trigger your symptoms such as exercise sleep posture environment? _ 2. Do your symptoms get worse with physical or mental activity? No Yes 3. Are you currently experiencing any of the following symptoms, now or recently? Chest pain Pale skin Neck Pain Shortness of breath Light-Headedness Swelling in your left arm Blackouts Left arm pain Jaw pain Excessive sweating without exertion Patient Medical History Page 4 of 8
Patient Name: Nausea Vomiting Dizziness or vertigo Abnormal sweating Double vision Numbness feeling unsteady Blurred vision Balance problems Headache 5. Have you noticed any of the following? Recent fever Change in appetite Memory issues Unexplained weight loss Drowsiness Brain Fog Confusion Sensitivity Light Pressure in head Sensitivity to Sound Recent fatigue Unexplained weight gain More Emotional Seizures Patient Authorization an accurate clinical picture so as to make an appropriate diagnosis and treatment plan. Please sign below authorizing that the information in this form has been read and filled out completely and accurately to the best of your understanding. Also, understand that the information in this form is considered confidential and for use by your doctor at Cerebrum Health Centers. Any disclosure is outlined in our privacy policies. Patient s (or guardian s) signature Date Patient s (or guardian s) printed name Date Signature of translator or person assisting you (if any) Doctor s Notes. Cerebrum Health Centers - Dallas 11511 Luna Rd, Suite 100, Dallas, TX 75234 Phone: 855-444-2724 Fax: 972-812-1160 Patient Medical History Page 5 of 8