Date: _________________________________________________________

Referring Physician: ___________________________________________

Utah Neurological ClinicUtah Neurological ClinicUtah Neurological ClinicUtah Neurological Clinic

1055 North 300 West, Suite 400

Provo, Utah 84604

Telephone: (801) 357-7404

PLEASE FILL OUT COMPLETELY. ACCURATE INFORMATION HELPS YOU.

Patient Name: ____________________________________________

Birthday: _________________________________________________

Present Age: _____________________________________________

Right or Left Handed: _____________________________________

1. Do you have a Latex allergy? Yes ________ No ________Do you have a Latex allergy? Yes ________ No ________Do you have a Latex allergy? Yes ________ No ________Do you have a Latex allergy? Yes ________ No ________

2. What is/are your chief area(s) of pain? Please check all those that apply.

Head ______ Neck ______ Upper back ______ Lower back ______ Shoulder(s) ______

Arm(s) ______ Buttocks ______ Leg(s) ______

3. Date of injury ____________ Was it work related? ________ Was it auto related? ________

Were you wearing a seat belt? _______ Please describe your injury __________________________________

__________________________________________________________________________________________________

4. How frequently do you experience pain? Please circle one.

10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

5. Are you experiencing any muscle weakness? Yes _____ No _____ Where? _______________________

6. Are you experiencing any numbness or pain? Yes _____ No _____ Where? _______________________

7. Are you having any headaches caused by this injury? Yes _____ No _____

How often? _____________ Where are the headaches located? Please check all of those that apply.

Front _____ Back _____ Top _____ Side _____ Behind the eyes _____

8. Have you had any of the problems below? Please check all those that apply.

Numbness or tingling in: Arm(s) ____ Leg(s) ____ Face ____ Difficulty walking ____

Poor Coordination ____ Neck pain ____ Back pain ____ Arm pain ____ Leg pain ____ Tremor ____

Stroke or CVA ____

9. Is there anything that alleviates the problem? Please describe ______________________________________

__________________________________________________________________________________________________

10. Is there anything that aggravates the problem? Please describe ___________________________________

__________________________________________________________________________________________________

2

Laboratory DataLaboratory DataLaboratory DataLaboratory Data

11. Have any tests been performed to evaluate this problem? Yes _____ No _____

Please indicate if you have had any of the following studies and the results as you understand them.

STUDYSTUDYSTUDYSTUDY WHENWHENWHENWHEN WHEREWHEREWHEREWHERE RESULTSRESULTSRESULTSRESULTS

Plain X-rays

MRI scan

Bone scan

Discogram

CT/Myelogram

NCV/EMG

Medical HistoryMedical HistoryMedical HistoryMedical History

12. Do you have, or have you been treated for any medical conditions? Please check all those that apply.

Lung/Breathing problems yes no Heart disease/Myocardial infarction yes no

High Blood Pressure/Hypertension yes no Liver Disease yes no

Kidney Disease yes no Thyroid Disease yes no

Diabetes yes no Cancer yes no

Stomach Problems yes no Urinary/Bladder yes no

Infectious Disease yes no Arthritis yes no

Sinus Disease yes no Allergies yes no

Dental/TMJ yes no Headache yes no

Seizure/Epilepsy yes no Stroke Yes no

Multiple Sclerosis yes no Parkinson’s Disease yes no

Depression/Anxiety yes no Psychiatric Disorder yes no

Head Injury yes no Spine Injury yes no

Mental Retardation yes no Learning Disability yes no

Surgical HistorySurgical HistorySurgical HistorySurgical History

13. Please list below, in order (most recent first), your surgical history.

DATEDATEDATEDATE OPERATIONOPERATIONOPERATIONOPERATION BY WHOMBY WHOMBY WHOMBY WHOM WHEREWHEREWHEREWHERE COMPLICATIONSCOMPLICATIONSCOMPLICATIONSCOMPLICATIONS

3

MedicationsMedicationsMedicationsMedications

14. Please list the medications you are taking for pain: __________________________________________________Other medications: ________________________________________________________________________________

AllergiesAllergiesAllergiesAllergies

15. Are you allergic to any medications? Please list: ____________________________________________________

HabitsHabitsHabitsHabits

16. Do you smoke? Yes ____ No ____ How many years? _______ How many packs per day?_______

17. Do you drink alcoholic beverages? Yes ____ No ____

Family HistoryFamily HistoryFamily HistoryFamily History

18. Has anyone in your family had, or is anyone being treated for the following? Please check anddescribe.

Yes/No Who? Yes/No Who?

Epilepsy/Seizure Yes No __________________ Parkinson’s Disease Yes No __________________

Stroke Yes No __________________ Migraine Headaches Yes No __________________

Paralysis Yes No __________________ Heart Disease Yes No __________________

Nerve Disease/numbness Yes No __________________ Diabetes Yes No __________________

Muscle disease/weakness Yes No __________________ Hypertension Yes No __________________

Alzheimer’s/dementia Yes No __________________ Cancer Yes No __________________

Alcoholism Yes No __________________ Mental Retardation Yes No __________________

Back/Neck pain Yes No __________________ Arthritis Yes No __________________

19. Has anyone in your family had symptoms like yours? Please describe: ________________________________

_________________________________________________________________________________________________

Social HistorySocial HistorySocial HistorySocial History

20. Occupation: __________________________ Are you working?________ Last date worked: _______________

21. Please note your physical work requirements: Heavy ____ Moderate ____ Light ____ Sedentary ____

22. What is your marital status? Married ____ Single ____ Divorced ____ Widowed ____ Separated ____

23. Do you have any children? Yes ____ No ____ How many? ______

4

Review of SystemsReview of SystemsReview of SystemsReview of Systems

24. Have you experienced any of the following in the last six months? (please check those that apply):

CONSTITUTIONAL Date

Good general health lately Yes No

Recent weight change Yes No

Fever Yes No

Fatigue Yes No

Headaches Yes No

EYES

Eye disease or injury Yes No

Wear glasses/contact lenses Yes No

Blurred or double vision Yes No

Glaucoma Yes No

ENT

Hearing loss Yes No

Ringing in the ears Yes No

Earaches or drainage Yes No

Sinus Problems Yes No

Nose bleeds Yes No

Mouth sores Yes No

Bleeding gums Yes No

Bad breath or bad taste Yes No

Sore throat or voice change Yes No

Swollen glands in neck Yes No

CARDIOVASCULAR

Heart trouble Yes No

Chest pains Yes No

Sudden heart beat changes Yes No

Swelling of feet, ankles or hands Yes No

RESPIRATORY

Frequent coughing Yes No

Spitting up blood Yes No

Shortness of breath Yes No

Asthma or wheezing Yes No

GASTROINTESTINAL

Loss of appetite Yes No

Change in bowel movements Yes No

Nausea or vomiting Yes No

Frequent diarrhea Yes No

Painful bowel movements

or constipation Yes No

Blood in stool Yes No

Stomach pain Yes No

Loss of taste Yes No

Difficulty swallowing Yes No

GENITOURINARY

Frequent urination Yes No

Burning or painful urination Yes No

Blood in urine Yes No

Change of force of strain

when urinating Yes No

Incontinence or dribbling Yes No

Kidney stones Yes No

Male - testicle pain Yes No

GENITOURINARY (cont) Date

Female

- pain w/periods Yes No

- irregular periods Yes No

- vaginal discharge Yes No

- # pregnancies _______ # miscarriages _______

- date of last pap smear ______________________

- findings of last pap smear ” Normal ” Abnormal

MUSCULOSKELETAL

Joint pain Yes No

Joint stiffness or swelling Yes No

Weakness of muscles or joints Yes No

Muscle pain or cramps Yes No

Back pain Yes No

Cold extremities Yes No

Difficulty in walking Yes No

SKIN

Rash or itching Yes No

Change in skin color Yes No

Change in hair or nails Yes No

Varicose veins Yes No

Breast pain Yes No

Breast lump Yes No

Breast discharge Yes No

NEUROLOGICAL

Frequent or recurring headaches Yes No

Lightheaded or dizzy Yes No

Convulsions or seizures Yes No

Numbness or tingling sensations Yes No

Tremors Yes No

Paralysis Yes No

Stroke Yes No

PSYCHIATRIC

Memory loss or confusion Yes No

Nervousness Yes No

Depression Yes No

Sleep problems Yes No

ENDOCRINE

Glandular or hormone problem Yes No

Thyroid disease Yes No

Excessive thirst or urination Yes No

Heat or cold intolerance Yes No

Dry skin Yes No

Change in hat or glove size Yes No

HEMATOLOGICAL/LYMPHATIC

Slow to heal after cuts Yes No

Easily bruising or bleeding Yes No

Anemia Yes No

Phlebitis Yes No

Past transfusion Yes No

Enlarged glands Yes No

5

Using the symbols below, please mark the areas on your body where you feel the described sensation. Please

include all affected areas.

Aching Numbness Pins & Needles Burning Stabbing Other

•• = = = + + + X X X //// ••

FRONT BACK

Where is your pain the worst? Please check those that apply.

Arms and Neck Equally

Arms Mostly

Neck Mostly

Legs and Back Equally

Legs Mostly

Back Mostly

6

25. Do you have a Workers’ Compensation hearing scheduled? _______ When _______

26. Is an attorney helping you with respect to your injury? __________________________________________

27. Are you being compensated for lost wages? ___________________________________________________

28. Relative to your current problems, have you been pleased with the medical treatment you have

received up to this time? _________________________________________________________

29. Please list any limitations to your normal activities that you are currently experiencing:

______________________________________________________________________________________________

______________________________________________________________________________________________

30. What do you wish to accomplish with today’s visit: _____________________________________________

______________________________________________________________________________________________

I attest that the information noted above currently represents my symptoms and medical history.

_________________________________________________________ __________________________________

Signature Date

_________________________________________________________ __________________________________

Physician Signature Date

Patient info form 031607