Comprehensive Neurology Center | Forms | Patient Past Medical History

Patient Past Medical History

First Name Required*

Last Name Required*

Email Required*

Date Of Birth Required*

Past Medical History Required*

None

Other Medical History

Social History Required*

Tobacco Use

Non Smoker

Smoker

Former Smoker

Quit Date

How Often Do You Smoke

Daily

Some days, but not every day

#Of Cigarettes some in a day

Alcohol Use Required*

How often did you have a drink containing alcohol in the past year?

Never

Monthly or less

2 to 4 times a month

2 to 3 times per week

4 or more times a week

How many drinks did you have on a typical day when you were drinking in the past year?

1 or 2 3 or 4

5 or 6

7 to 9

10 or more

How often did you have six or more drinks on one occasion in the past year?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Family History Required*

Check if any first degree relative has any Medical Problem

Medical Conditions	Father	Mother	Siblings
High Blood Pressure	Yes No	Yes No	Yes No
High Cholesterol	Yes No	Yes No	Yes No
Heart Disease	Yes No	Yes No	Yes No
Diabetes	Yes No	Yes No	Yes No
Stroke	Yes No	Yes No	Yes No
Cancer	Yes No	Yes No	Yes No
Migraines	Yes No	Yes No	Yes No
Thyroid Issues	Yes No	Yes No	Yes No
Alcoholism	Yes No	Yes No	Yes No
Mental Illness	Yes No	Yes No	Yes No
Others/Specify	Yes No	Yes No	Yes No

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