Associates In Neurology
Main Office
27555 Middlebelt Rd
Farmington Hills, MI 48334
Phone (248) 478-5512 Fax (248) 478-5350
Providence Novi
26850 Providence Pkwy Suite 210
Novi, MI 48374
Phone (248) 735-0502 Fax (248) 735-0507
Providence Medical Building
22250 Providence Dr Suite 602
Southfield, MI 48075
Phone (248) 443-1666 Fax (248) 443-0468
Oakland Medical Building
1435 N. Milford Rd
Milford, MI 48381
Phone (248) 685-8435 Fax (248) 685-2251
Date:
Patient Name:
Date of Birth:
FAMILY/INTERNAL MEDICINE DOCTOR
REFERRING DOCTOR (if same, write same)
Name:
Name:
Address:
Address:
Phone:
Phone:
Current Medications - INCLUDING NAME, DOSAGE, AND HOW MANY TIMES TAKEN
Current Allergy List:
Patient History Information and Review of Systems
Past Medical HistoryMedical:
Surgical:
Transfusion History:
Childhood Diseases:
Family HistoryGeneral Family Illness:
Father:
Mother:
Social HistoryAlcohol Use:
Tobacco Use:
Caffeine:
Exercise:
Pets in Home:
Please list your current pharmacy information:
Name:
Phone Number:
Address:
City:
Zip Code:
Please Check all symptoms that apply:
General
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Anorexia
Appetite Loss
Chills
Dietary Change
Excessive Crying
Fatigue
Feeling well
Fever
Medication Changes
Night Sweats
Obesity
Persistent Infections
Shakiness
Tiredness
Unable to sleep lying flat
Weight gain 5-10lbs
Weight gain > 10lbs
Weight gain
Weight loss 5-10lbs
Weight loss > 10lbs
Weight loss
None
Endocrine
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Appetite Changes
Cold Intolerance
Decreased Sweating
Excessive Sweating
Excessive Thirst
Excessive Urination
Hair Changes
Heat Intolerance
Hot Flashes
Libido Chane
Polydipsia
Polyuria
Sexual Dysfunction
Thyroid Problems
None
Skin
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Brittle Nails
Bruising
Change in wart/mole
Clamminess
Coarse Hair
Coarse Skin
Cold Skin
Cracked Lips
Dryness
Excessive Sweating
Hair Growth
Hair Loss
Hives
Itching
Nail changes
New Lesions
Pruritus
Pallor
Rash
Skin Color Changes
Ulcer
None
Hematology
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Abnormal bleeding
Anemia
Blood clots
Easy bruising
Englarged lymph nodes
Epistaxis
Excessive bleeding
Gland problems
Nose bleed
Painful lymph nodes
Petechiae
Pinpoint hemorrhages
Prolonged bleeding
Spontaneous bleeding
None
HEENT
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Headache
Head injury
Facial numbness/tingling
Blurred vision
Color blindness
Decreased night vision
Diplopia
Double vision
Excessive tearing
Eye pain
Eye redness
Glaucoma
Periorbital puffiness
Visual disturbances
Visual loss
Wears glasses/contact lenses
Hearing loss
Deafness
Decreased hearing
Ear discharge
Ear infection
Ear pain
Earache
Ringing in the ears
Tinnitus
Spinning sensation
Vertigo
Coryza
Dry mucous membranes
Runny nose
Nose bleed
Epistaxis
Decreased sense of smell
Frequent colds
Nasal congestion
Sneezing
Seasonal allergies
Sleep apnea
Rhinitis
Sinus pain
Snoring
Bleeding gums
Choking sensation
Decreased sense of taste
Difficulty chewing
Drooling
Hoarseness
Oral ulcers
Sore throat voice changes
None
Neck
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Musculoskeletal
Neck mass
Neck pain
Neck stiffness
Neck swelling
Swollen glands
None
Repiratory
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Bloody sputum
Chronic cough
Cough
Decreased exercise
tolerance
Difficulty breathing
Difficulty breathing on
exertion
Dyspnea
Hemoptysis
Snoring
Sputum production
Wakes up from sleep
wheezing or short of
breath
Wheezing
None
Breast
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Breast mass
Breast pain
Breast swelling
Nipple discharge
Nipple pain
Recent breast size change
Skin changes
None
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Back pain
Backache
Calf pain
Claudication
Decreased range of
motion
Fasciculations
Joint pain
Joint redness
Joint stiffness
Joint swelling
Leg cramps
Muscle atrophy
Muscle cramps
Muscle pain
Muscle pain
Muscle weakness
Myalgia
Physical disability
Swelling of extremities
None
Psychiatric
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Anxiety
Change in sleep pattern
Delirium
Delusions
Depression
Disorientation
Early awakening
Easily irritated
Fearful
Frequent crying
Hallucinations
Hypersomnia
Impaired cognitive
function
Inability to concentrate
Insomnia
Memory loss
Mood changes
Nervousness
Panic attacks
Personality changes
Suicidal ideation
Suicidal planning
Trouble falling asleep
None
Neurological
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Attention deficit
Auras
Decreased memory
Difficulty speaking
Dizziness
Dysarthria
Dysesthesia
Easily distracted
Fasiculations
Fainting
Focal neurological
symptoms
Headaches
Hyperactivity
Incontinence stool
Incontinence urine
Incoordination
Loss of consciousness
Muscle twitching
Numbness
Paresthesias
Seizures
Slow reflex relax
Spinning sensation
Stroke
Syncope
Tingling
Tremor
Trouble walking
Unusual sensation
Unsteadiness
Vertigo
Visual changes
Weakness
Weakness in extremities
None
Cardiovascular
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Abnormal blood pressure
Bradycardia
Calf cramps
Chest pain
Claudications
Difficulty breathing lying down
Difficulty breathing on exertion
Edema
Elevated blood pressure
Fainting
Fainting/blacking out
Heart stent
Hypertension
Irregular heart beat
Leg cramps
Orthopnea
Palpitations
Paroxysmal nocturnal dyspnea
Phlebitis
Rapid heart rate
Shortness of breath
Slow heart rate
Swelling of extremities
None
Gastrointestinal
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Abdominal mass
Abdominal pain
Abdominal swelling
Belching
Black, tarry stool
Change in bowel habits
Chronic diarrhea
Constipation
Diarrhea
Difficulty swallowing
Dysphagia
Excessive gas
Food intolerance
Gas
Gets full quickly at meals
Hematemesis
Hemorrhoids
Heartburn
Hyperdefecation
Hyperphagia
Incontinence of stool
Indigestion
Jaundice
Laxative use
Melena
Nausea
Painful swallowing
Pain with bowel movement
Rectal bleeding
Stool has tested positive for blood in the past 6
months
Stool has not tested positive for blood in the
past 6 months
Vomiting
Vomiting blood
None