Please Complete and Bring with You to Your Appointment

STROKE CLINIC QUESTIONNAIRE

PLEASE COMPLETE AND BRING WITH YOU TO YOUR APPOINTMENT

Name:______Date:______

If you are seeing one of our physicians for the first time, we would appreciate you answering the following questions. This will give us a clear picture of your overall health, and allow your doctor to help you better with your neurological problem.

REASON FOR VISIT

What is the complaint or problem you are having? ______

When did this problem begin? ______Is this a NEW or OLD problem? ______

Were you hospitalized? If YES, when and where were you hospitalized? ______

Have you seen any doctors for this problem? ______If YES, who did you see? ______

Did a doctor refer you to see us? If yes, who referred you? ______

Primary care doctor: Name ______Phone ______

Other providers: Specialty ______Name______Phone______

Pharmacy: ______Phone ______Location ______

PERSONAL/SOCIAL HISTORY

MEDICATIONS (Please list all medications you are currently taking including over the counter medications;and/or bring all of your medication bottles with you)

Please list any allergies to medications ______

Name______Dosage______Times per day______

PAST MEDICAL HISTORY: (Do you currently have, or were told you had any of the following problems?)

TIA (Transient ischemic attack)Yes/No StrokeYes/No

High blood pressure (Hypertension)Yes/NoHigh cholesterolYes/No

Diabetes (Elevated blood sugar)Yes/NoMyocardial infarction (Heart attack) Yes/No

Blockage in Carotid artery (stenosis)Yes/NoPatent Foramen Ovale (PFO)Yes/No

Atrial fibrillation Yes/NoCongestive heart failure Yes/No

Arterial dissection (tear in the artery)Yes/NoSickle Cell diseaseYes/No

Moyamoya disease Yes/NoAutoimmune disorder (Lupus) Yes/No

Clotting DisorderYes/NoGenetic DisorderYes/No

FAMILY HISTORY

MemberAlive? Medical Problems or Cause of Death

MotherY/N______

FatherY/N______

SiblingsY/N______

REVIEW OF SYSTEMS/GENERAL MEDICAL PROBLEMS: (Do you currently have any of the following problems? Check all problems below.)

General Problems

Weight loss or gain

Fatigue

Fever or chills

Weakness

Trouble sleeping

Skin Problems

Rashes

Itching

Dryness

Color changes

Head and Neck

Headache

Head injury

Neck Pain

Ears/Eye Problems

Decreased hearing

Ringing in ears

Vision Loss/Changes

Glasses or contacts

Blurry or double vision

Flashing lights

Glaucoma

Cataracts

Breast Problems

Lumps

Pain

Signature ______Date______