Advanced Neurology Center LLC - Medical History Form

MEDICAL HISTORY QUESTIONNAIRE

Patient's Name:

DOB:

Age: Yrs.

Handedness: Right Left Ambidextrous

Medical History: List any medical problems diagnosed before:

Surgical History:List all prior operations:

Do you have a history of significant trauma or accidents:

Do You Have any metallic devices/objects in your body:

Family History:

Work History: Please list all your past & present occupations:

Any exposure to toxic chemicals: TOBACCO: Cigarettes Cigars

Number smoked in a day: Number of years smoking:

ALCOHOL: What Kind: Number of drinks/week:
Recreational Drugs:

LIST ALL CURRENT PRESCRIBED MEDICATIONS:

ALLERGIES TO MEDICATIONS: Name of Drug - Reactions You Had