Cooper Neurological Institute Phone: Fax:

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Cooper Neurological Institute Phone: 856-968-7965 Fax: 856-968-8697 PATIENT INFORMATION AND HEALTH HISTORY Name: Date: Birth date: Age: Home Phone: Cell Phone: If patient is a minor or disabled, please provide name of parent or legal guardian and phone number _ Emergency Contact: Name Phone Primary Care physician: Address: Phone: Fax: Referring physician: Address: Phone: Fax: Please list any other physician or specialist that is treating you (i.e. Cardiologist, Endocrinologist, Neurologist, Pain Mgt) Name Address and Phone Height: Weight: Right-handed Left-handed Ambidextrous Are you involved in any litigation with regards to your health? No Yes If yes, please provide details and your attorney s name and phone number: Chief Complaint and History of Present Illness What is your major complaint, symptoms, or reason that brought you to see a neurosurgeon (i.e. headaches, seizures, arm or leg weakness, change in vision, abnormal MRI, CAT scan etc.)? When did you first notice any symptoms? What makes your symptoms better? What makes your symptoms worse? Page 1 of 6 Brain

Please rate your pain on a scale from 0-10: 0 1 2 3 4 5 6 7 8 9 10 If you have any pain, please describe it: dull, sharp, constant, stabbing, numb, tingling, electric-like, ache What triggers the pain or what time of day does the pain start? Please rate your fatigue level on a scale from 0-10: 0 1 2 3 4 5 6 7 8 9 10 Please rate your nausea level on a scale from 0-10: 0 1 2 3 4 5 6 7 8 9 10 Please list below any tests you have had related to this problem: Type of test Where was the test done Month/year done Dr. who ordered test Past Medical History Please note any illness or medical condition that you have had IN THE PAST: COMMENTS COMMENTS anemia heart rhythm abnormality aneurysm hepatitis type: arthritis high blood pressure asthma high cholesterol bleeding (brain) hyperthyroid (high) blood clot hypothyroid (low) brain/spine/nerve injury kidney disease bronchitis migraines cancer type: osteoarthritis treatment: osteoporosis type: Parkinson s disease treatment: pituitary tumor concussion pneumonia COPD/emphysema scoliosis degenerative disc disease seizures diabetes sleep apnea dystonia stroke fibromyalgia TIA gall bladder problems tuberculosis GERD ulcers heart attack valve disorder (heart) heart failure/chf heart murmur Past Surgical History Please list ALL previous surgeries you have had: Type of Surgery Year or Age Page 2 of 6 Brain

Please list all current medications, vitamins, herbs or over the counter medications that you are taking: Medication Dose Frequency When did you start the medication? Prescribing Doctor 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Do you have any allergies to any medications? No Yes If yes please list below Medication Type of Reaction Do you have an allergy to latex? No Yes Type of Reaction: Do you have an allergy to tape? No Yes Type of Reaction: Do you have an allergy to iodine or contrast dye? No Yes Type of Reaction: Do you have an allergy to any foods? No Yes List: Do you have seasonal or environmental allergies? No Yes List: Social, Smoking and Drug History Do you smoke presently? No Yes If yes, what do you smoke? How much do you smoke? Are you an ex-smoker? No Yes If yes, when did you stop? How much did you used to smoke? Do you drink alcohol? No Yes If yes, what do you drink? How much do you drink? Are you an ex-drinker? No Yes If yes, when did you stop? Do you use recreational or illegal drugs? No Yes If yes, please list Do you drink caffeinated beverages? No Yes If yes, how many per day? Do you wear glasses or contacts? No Yes Do you wear dentures? No Yes If yes: uppers lowers What is your occupation? Are you currently working? Yes No If no, when did you stop? With whom do you live? Who is your legal next of kin? Family Medical History Please list any medical condition (i.e. stroke, diabetes, heart disease, cancer, Parkinson s disease, Alzheimer s disease, multiple sclerosis, seizures, brain tumors, aneurysms, neurofibromatosis) that you feel would be important for us to know: Mother Sibling Father Child Maternal grandparent Paternal grandparent Page 3 of 6 Brain

Review of Systems Please check any symptoms below that you currently have in the following areas: HEART/VASCULAR edema/swelling angina/chest pain poor circulation irregular heart beat palpitations phlebitis clotting/bleeding problems easy bruising NEURO numbness/tingling balance problems/ unsteady gait tremors/twitching hemorrhage (brain) difficulty walking coordination problems fainting dizziness weakness memory problems headache/migraines slurred speech loss of consciousness SKIN rash psoriasis lesions moles discoloration itching birthmarks ulcers/pressure sores MUSCULOSKELETAL painful joints limited mobility chronic muscle pain swollen joints weakness muscle spasms EYE blurry vision loss of vision double vision eye redness excessive tearing eyelid drooping eye discharge/drainage URINARY frequent urination burning during urination blood in urine difficulty with urination bladder control problems change in bladder function tumor or cysts kidney stones RESPIRATORY wheezing chest pain persistent coughing hiccups sleep apnea shortness of breath EAR/NOSE/THROAT ear discharge/drainage hearing loss/difficulty ringing in ears/tinnitus pain with swallowing nosebleeds ulcers/sores decreased smell decreased taste PSYCHIATRIC anxiety depression schizophrenia ADHD sleep disturbance ENDOCRINE excessive sweating hot flashes excessive thirst urinating at night nipple discharge GASTROINTESTINAL heartburn difficulty swallowing nausea/vomiting excessive weight loss excessive weight gain constipation loss of appetite diarrhea blood in stools change in bowel habits bowel control problems last colonoscopy GENITALS / BREASTS tumor erectile dysfunction enlarged prostate nipple discharge menopause sexual dysfunction date of last mammogram LMP Page 4 of 6 Brain

Date of last vaccinations PPD/TB Pneumonia Flu Tetanus Cultural/Linguistic Needs Are there any language barriers, visual and/or auditory deficits, as well as any cultural or religious customs that may interfere with our ability to provide your care? No Yes If yes, please explain: Do you have a Living Will or Advanced Directive? No Yes To the best of my knowledge, the information that I have supplied on this form is current and complete. Patient Signature Date Physician Signature Date The review of systems has been reviewed in its entirety with the patient. All positive items are indicated as above and all other systems are negative. Page 5 of 6 Brain

I have reviewed the previous information with the patient and changes have been noted in the progress note: Date Physician s Signature Additional Information Page 6 of 6 Brain

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