New River Neurology and Epilepsy .

Chunxiao Belinda Zhang, MD Theresa Buchanan, NP

125 Akers Farm Road

Christiansburg, VA 24073

PH 540.381.9480 FX 540.381.9483

Patient History Form

Patient Name: ______DOB ______

Right or Left handed (circle one)

Past Medical HistoryDATE ______

1. Please list physicians who currently deal with your health:

Name: ______Problem(s): ______Specialty: ______

Name: ______Problem(s): ______Specialty: ______

Name: ______Problem(s): ______Specialty: ______

Name: ______Problem(s): ______Specialty: ______

2. Have you ever had any of the following diseases or conditions? Please check the box and note when it started.

Headaches ______

Vision changes (double vision, blurry vision, loss of vision, etc.) ______

Ear problems (ringing, loss of hearing, etc.) ______

Nose problems (congestion, runny nose, etc.) ______

Trouble chewing or swallowing ______

Heart disease (heart attacks) ______

Rheumatic fever ______

High blood pressure ______

High cholesterol ______

Anemia or other blood problems ______

Lung disease (asthma, emphysema, etc.) ______

Kidney or bladder disease (infections, stones, etc.) ______

Liver disease (cirrhosis, hepatitis, etc.) ______

Cancer ______

Arthritis ______

Bleeding problems ______

Diabetes ______

Thyroid disease ______

Stomach problems ______

Gallbladder disease ______

Seizures (epilepsy) ______

Strokes or paralysis ______

Psychiatric problems ______

Skin problems ______

Other (please list) ______

Patient Name: ______DOB ______

3. Please list previous surgeries (start with the most recent first):

DATEREASON

______

______

______

______

______

4. Are you allergic to any medications or food? If so, please list, and include the reaction you have had:

______

5. Please list all current medications you are taking. Include over the counter medications, antacids, laxatives, birth control, vitamins, herbs, etc.

Medication NamePill strength# of pills taken at each dose How many times each day

______

______

______

______

______

______

______

______

______

______

______

______

______

______

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(If you need more room, please list on the back)

Patient Name: ______DOB ______

Family Medical History

FatherMotherFather’sMother’sSiblingsChildren

ParentsParents

Asthma

Allergies

Heart disease

High blood pressure

Stroke

Cancer

Ulcers

Mental illness

Liver disease

Diabetes

Epilepsy

Kidney disease

Arthritis

Gout

Please list any other significant illnesses in family members: ______

______

Social History:

1. Who provides the most ongoing emotional support to you? ______

2. Have you traveled outside the U.S. in the past year? Yes No

3. Have you ever smoked? YesNo If yes, do you still smoke? YesNo

If you ever smoked, how many packs per day? ______For how long? ______

If you smoked in the past but quit, when did you quit? ______

4. Do you drink alcohol? Yes No If yes, how much? ______For how long? ______

5. Do you use recreational drugs? YesNo If yes, how often? ______

6. Do you exercise? Yes NoIf yes, what kind? ______How often? ______

7. Do you use seat belts? YesNo

patient/ guardian signature ______Date ______

Updated 11/13/2018