Neurosurgery Clinic
2211 Lomas Blvd. NE Albuquerque, NM 87106
(505) 272-9494
Dear_______________________,
MRN_______________________
You have been scheduled for an appointment with Dr.______________________
In the Neurosurgery Clinic on________________ at _________________AM/PM.
Enclosed in this packet, you will find a new patient questionnaire regarding your
medical history and current problems. Please fill this out and bring it with you to
your appointment. Remember to bring your current list of medications, including
over the counter medications and vitamins.
If you need to reschedule or cancel your appointment, please call as soon as
possible at (505) 272-9494.
Please remember to bring your referral, all MRI or CT films, and co-pay with you.
Failure to do so may cause your appointment to be rescheduled.
Appointment Preparation
Completed new patient questionnaire
Current list of medications
Referral
All MRI or CT films
Co-pay
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Neurosurgery Clinic
2211 Lomas Blvd. NE Albuquerque, NM 87106
(505) 272-9494
Personal Medical History
1. Allergies (if any):
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
2. Past Medical History:
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
3. Prior Surgical History
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
4. Family History of Medical Problems
Mother:_____________________________________________
___________________________________________________
Father:______________________________________________
___________________________________________________
Siblings:
___________________________________________________
___________________________________________________
___________________________________________________
5. Occupation:_____________________________________________
6. Alcohol use? If yes, how often?
___________________________________________________
7. Tobacco use? If yes, how often?
___________________________________________________
8. Other drug use? If yes, what and how often?
___________________________________________________
___________________________________________________
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Neurosurgery Clinic
(505) 272-9494
Personal Medical Review
(check all items that apply)
General
Weight gain or loss of > 5
pounds in last 6 months
Fever or night sweats
Fatigue
Poor appetite
Eyes
Blurred/Double Vision
Blind Spots
Cataracts
Glaucoma
Eye Pain
Ears/Nose/ Mouth/ Throat
Loss of hearing
Ringing of ears
Congested or bloody nose
Fluid coming from ears
Pain in or near the ears
Sinus problems
Bad teeth or gums
Difficulty chewing
Difficulty swallowing
Loss of taste
Sore throat
Sores in mouth
Cardiovascular (Heart)
High blood pressure
High cholesterol
Chest pain/pressure
Irregular heart beat
Heart murmur
Bad arteries/veins
Swelling in feet/legs
Respiratory (Lungs)
Shortness of breath
Asthma
Pneumonia/Bronchitis
Cough
Gastrointestinal
Abdominal pain/ swelling
Heartburn
Ulcer
Liver disease
Diarrhea/constipation
Diverticulitis/Colitis
Black/bloody stools
Rectal bleeding
Kidney disease
Bladder incontinence
Blood in urine
Frequent bladder infections
Hematological
Leukemia/Lymphoma
History of blood transfusion
Anemia
Easy bleeding/bruising
Blood clots
Endocrine
Diabetes
Low blood sugar
Thyroid disease/goiter
Psychological
Anxiety/Panic attacks
Depression
Mental Illness
Dermatologic
Rash or infection of the
skin
Change in mole
Sore that will not heal
Reproductive
Breast disease
Pelvic pain
Irregular menstrual cycle
Excessive bleeding
Birth control pills
Hormone supplement
Prostate problems
Impotence
Neurological
Difficulty speaking or
writing/understanding
Poor memory
Personality change
Loss of consciousness
Seizures
Frequent headaches
Weakness
Clumsiness
Numbness/Tingling
Difficulty walking
Loss of balance
Dizziness
Infectious Disease
Tuberculosis
Hepatitis
HIV/AIDS
Lyme Disease
Musculoskeletal
Broken bones
Dislocated joints
Osteoporosis
Painful/swollen joints
Muscle pain/spasms
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