Diplomate of the Americanacademy of Neurology

Barry L. Katchinoff, M.D.

Diplomate of the AmericanAcademy of Neurology

Diplomate of the American Board of Sleep Medicine

Medical Questionnaire

Name: ______Date: ______

Referring Physician: ______

Primary Care Physician: ______

Are you?RIGHT HandedLEFT Handed BOTH

What is the main problem for which you are being seen today? ______

How long have you had this problem? ______

Social History: (circle/fill in best answer)

Marital Status: MarriedSingleLife Partner Separated DivorcedWidowed

Tobacco Use: Neverpreviously, but quit Current, packs per day ______

Alcohol Use:Do you currently drink alcohol? Yes or No

How much per day? ______per week? ______

Drug Use:Neverpreviously, but quitType & Frequency ______

Caffeine Use:NeverCups per day ______

Occupation:Do you work outside of the home? Yes No Retired

What kind of work do you do? ______

Do you work shifts? Yes NoVariable or Stable? ______

Exposure:Do you have excessive exposure at home or work to:

fumes dust solvents air-borne particles

Family History: (complete all that applies)

Age at Onset Disease(s) If deceased, cause of death

Father ______

Mother______

Brother(s)______

______

Sister(s)______

Children (How many?)______

______

______

Name: ______Date: ______

Medication(s): (please list all medications that you currently take. Include medications

that you take on an “as needed” basis.) Use separate sheet for more.

Name of Drug Dosage How many per Day

______

______

______

______

______

Vitals:

Height: ______’______”Weight:______

Allergies: Yes No Are you allergic to Latex? Y N

If yes, please list: Medication Symptoms you experience

______

______

______

Food Symptoms you experience

______

______

______Any other allergies Symptoms you experience

______

______

Past Surgical History:

Type of surgery When Where

______

______

______

Past Medical History: (please CheckYes or No)

Diabetes Type I or Type IIYesNo

HypertensionYesNo

Cancer of ______YesNo

StrokeYesNo

Heart TroubleYesNo

Rheumatoid ArthritisYesNo

OsteoarthritisYesNo

EpilepsyYesNo

Bleeding TendencyYesNo

Acute InfectionsYes No

Venereal DiseaseYesNo

Sleep ApneaYesNo

Hereditary DefectsYesNo

MigrainesYesNo

CholesterolYesNo

____ No past Medical History

Previous Testing:

When Where Results

CT Scan ______

MRI: ______

EEG: ______

Carotid Doppler ______

Sleep Study ______

Name: ______Date: ______

Review of Systems: (please circle yes or no)

Constitutional Symptoms:Musculoskeletal:

YNGood general health lately YNJoin pain

YNRecent weight loss YNJoint stiffness

YNRecent weight gain YNMuscle cramps

YNFever YNBack pain

YNFatigue

YNLoss of appetite Integumentary (skin)

Y NRash

Eyes: Y NItching

YNEye disease Y NChange in skin color

YNDouble vision

YNWear corrective lenses Sleep Problems:

YN Visual loss Y N Do you sleep well?

YNBlurred vision Y NLeg jerks at night?

Y NDo you snore?

Ears/Nose/Mouth/Throat: Y N Are you fatigued on awakening? Y N Hearing Loss Y N Stop breathing at night? Y N Ringing in ears Y N Grind your teeth? Y N Earaches

YNSwallowing problems Previous Diagnosis of:

YNChronic sinus problem Y N Sleep apnea

Y N Restless leg syndrome

Cardiovascular: Y N Narcolepsy Y N Heart disease Y N Chest pain Psychiatric:

YN Ankle swelling Y N Memory loss

YN Palpitations Y N Confusion

YN Shortness of breath with walking Y N Nervousness

YN Shortness of breath while lying flat Y N Depression Y N Irregular heart beat Y N Anxiety Y N Calf pain with activity

Endocrine:

Respiratory: Y N Thyroid disease

YN Frequent cough Y N Diabetes

YN Asthma Y N Excessive thirst

YN Wheezing Y N Heat intolerance

Y N Cold intolerance

Gastrointestinal:

Y N Diarrhea Neurologic:

Y N Nausea Y N Numbness

Y N Vomiting Y N Tingling

Y N Constipation Y N Speech difficulties Y N Blood in stool Y N Gait difficulties Y N Abdominal pain Y N One sided weakness Y N Heartburn Y N Tremor

Y N Ulcer Y N Fainting Y N Swallowing difficulties

Genitourinary:

YN Frequent urination Y N Blood in urine

YN Incontinence

YN Kidney stones

YN Sexual difficulties

YN Male/testicle pain

YN Female/irregular periods

YN Urgency

Y N Painful urination

1Revised1/05/10