WASHINGTON UNIVERSITY SCHOOL OF MEDICINE. Cranial Health History Form

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Transcription:

WASHINGTON UNIVERSITY SCHOOL OF MEDICINE Cranial Health History Form Welcome to the Neurosurgery Department at Washington University. To help us treat you, please fill this form out completely. Your Name: Today s Date: Your date of birth: Your age: Are you: right-handed left-handed ambidextrous Who referred you to us: Who is your primary care physician? If same as referring, check here: List any physicians you would like us to send our notes to: What problem are we seeing you for today: Past Medical History Neurological problems: YES NO TIA (transient ischemic attack) Stroke Brain bleed (intracerebral hemorrhage) Brain aneurysm Brain vascular malformation (AVM, cavernous malformation) Brain tumor (brain neoplasm Narrowing of carotid arteries (carotid artery stenosis) Seizures (convulsions) Dementia/Alzheimer s Disease Cervical disc disease Cervical stenosis Lumbar disc disease Lumbar stenosis Heart problems: Chest pain (angina, coronary artery disease) Heart Attack (myocardial infarction) Congestive Heart Failure High blood pressure (hypertension) Aortic insufficiency Mitral valve regurgitation Atrial fibrillation Mitral valve prolapse Page 1 of 5

Lung problems: YES NO Emphysema (COPD) Asthma Tuberculosis Endocrine problem: High thyroid levels (hyperthyroidism)................... Low thyroid levels (hypothyroidism).................... Diabetes......................................... GI problems (stomach, colon): Ulcers (peptic ulcer disease)........................ Reflux (gastroesophageal reflux disease)............... Hepatitis......................................... Liver failure...................................... Diverticulosis..................................... Kidney / bladder / prostate problems: Urinary infections (urinary tract infections)............... Kidney infections (pyelonephritis)...................... Kidney dysfunction no dialysis (renal insufficiency)....... Kidney dysfunction dialysis (renal failure).............. Polycystic Kidney Disease........................... Prostate enlargement (benign prostatic hypertrophy)...... Blood problems: Bleeding disorder................................. Deep vein thrombosis............................... Pulmonary Embolus................................ Taking blood thinner (coumadin, warfarin, aspirin, etc.)..... Immune problems: HIV............................................. AIDS............................................ Psychiatric problems: Depression....................................... Anxiety.......................................... Bipolar disorder................................... Psychosis....................................... Cancer: Lung............................................ Thyroid.......................................... Breast........................................... Colon........................................... Pancreas........................................ Prostate......................................... Kidney.......................................... Melanoma....................................... Other problems: Rheumatoid Arthritis................................ Marfan s disease.................................. Polyarteritis Nodosa................................ Possible pregnancy (women of childbearing age)...... Please list other active medical problems not noted above: (These are problems for which you are currently taking medication or are seeing another physician) Page 2 of 5

Past Surgical History Surgeries: YES NO DATE(S) Brain surgery (craniotomy) Shunt........................... Spinal surgery neck (cervical)....... Spinal surgery low back (lumbar).... Cataract surgery ( left; right)...... Heart bypass (CABG)............... Heart valve replacement............ Heart stent (angioplasty and stent).... Appendectomy................... Cholecystectomy................. Tonsillectomy.................... Please list other surgeries: Medications: (please list all medications you are taking, including over-the-counter medications such as aspirin, ibuprofen, herbal medications, etc.) Name Dose Name Dose Allergies: (Please list all medication and non-medication allergies.) YES NO UKNOWN Do you have an allergy to latex? Page 3 of 5

Family history: (please indicate any major medical problems in your family) Yes No Brain aneurysm............................. Cavernous malformation...................... Hereditary Hemorrhagic Telangiectasia........... Neurofibromatosis ( Type I; Type II)........... Von Hippel-Lindau disease..................... Brain tumor................................ Stroke.................................... Hypertension............................... Heart disease/heart attack..................... Other family medical history: Personal / social history: Your height: Your weight: Tobacco use: Never Previously used Year when you quit: Packs/day when using: Recently quit Packs/day when using: Current: Number of years using: Packs/day now using: Other nicotine use (chewing tobacco, cigar, pipe) Alcohol use: Martial status: Never/rarely Occasionally/socially Moderate (2 drinks/day on average) Heavy (more than 2 drinks/day on average) Single Married Separated Widowed Divorced Work status: Currently employed Page 4 of 5

Occupation: Not currently employed Retired On disability When disabled? Reason for disability? Review of systems: Have you recently had any of the following symptoms?: YES NO Tiredness / fatigue Fevers Chills Sweat heavily at night (night sweats) Recent weight loss (unintentional) Headache Chest pain Palpitations (heart racing) Shortness of breath Difficulty breathing during physical activity Cough Heartburn (acid reflux) Nausea Vomiting Easy bleeding Easy bruising Diffuse joint pains (arthralgias) Muscle aches Anxiety Depression Please answer yes or no to the following: YES NO Is this a workman s compensation case? Is this related to an injury or car accident? Are you currently involved in any litigation or lawsuits? Have you consulted a lawyer about your injury/problem? Physician Signature Date Page 5 of 5

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