Northtowns Neurology
Michael A. Meyer, MD
Patient Name:
1
Date of Birth:
PRIMARY CARE PHYSICIAN AND ADDRESS:
CHIEF COMPLAINT/REASON FOR VISIT:
PAST MEDICAL HISTORY:
PAST SURGICAL HISTORY:
CURRENT MEDICATIONS AND DOSAGES: (Please include pharmacy and phone #)
ALLERGIES:
2605 Harlem Road  Cheektowaga, New York 14225
Ph: (716) 891-2929  Fax: (716) 961-3767
Northtowns Neurology
Michael A. Meyer, MD
Patient Name:
2
Date of Birth:
SOCIAL HISTORY (ARE YOU A SMOKER? IF SO, HOW MUCH? DO YOU DRINK ALCOHOL, IF SO HOW
OFTEN?)
FAMILY HISTORY (PARENTS, SIBLINGS AND CHILDREN’S MEDICAL HISTORY, ALIVE OR DECEASED):
2605 Harlem Road  Cheektowaga, New York 14225
Ph: (716) 891-2929  Fax: (716) 961-3767
Northtowns Neurology
Michael A. Meyer, MD
3
Patient Name:
Date of Birth:
REVIEW OF SYSTEMS
NEUROLOGICAL:
Yes
☐
☐
☐
☐
☐
☐
☐
Changes in sight
Changes in smell
Changes in hearing
Changes in taste
Seizures
Headaches
Pins and needles or numbness
No
☐
☐
☐
☐
☐
☐
☐
Yes
Limb weakness
☐
Poor balance
☐
Sphincter disturbance
☐
Higher mental functions symptoms ☐
Memory loss
☐
Incoordination
☐
Psychiatric symptoms
☐
No
☐
☐
☐
☐
☐
☐
☐
Please describe any other neurologic symptoms:
EYES:
Yes
☐
☐
☐
Visual changes
Double vision
Scotomas (blind spots)
No
☐
☐
☐
Floaters
“looking through a curtain”
Eye pain
Yes
☐
☐
☐
No
☐
☐
☐
No
☐
☐
☐
☐
☐
Ringing in ears (tinnitus)
Gum bleeding
Toothache
Sore throat
Pain while swallowing
Yes
☐
☐
☐
☐
☐
No
☐
☐
☐
☐
☐
Paranoia
Lack of energy
Episodes of mania
Episodic changes in personality
Sexual dysfunction
Yes
☐
☐
☐
☐
☐
No
☐
☐
☐
☐
Please describe any other eye symptoms:
EARS, NOSE & THROAT :
Yes
☐
☐
☐
☐
☐
Runny nose
Frequent nose bleeds
Sinus pain
Stuffy ears
Ear pain
Please describe any other ear, nose and throat symptoms:
PSYCHIATRIC:
Yes
Depression
☐
Anxiety
☐
Difficulty concentrating
☐
Negative body image
☐
Decreased work/school performance ☐
No
☐
☐
☐
☐
☐
Please describe your sleep patterns:
Please describe any psychiatric symptoms not mentioned above:
2605 Harlem Road  Cheektowaga, New York 14225
Ph: (716) 891-2929  Fax: (716) 961-3767
☐
Northtowns Neurology
Michael A. Meyer, MD
Patient Name:
4
Date of Birth:
MUSCULOSKELETAL :
Joint pain
Misalignment
Joint swelling
Decreased range of motion
Functional deficit
Arthritis
Yes
☐
☐
☐
☐
☐
☐
No
☐
☐
☐
☐
☐
☐
Stiffness:
Morning
Day long
Improves with activity
Worsens with activity
Yes
No
☐
☐
☐
☐
☐
☐
☐
☐
Yes
☐
☐
☐
☐
No
☐
☐
☐
☐
Yes
☐
☐
☐
No
☐
☐
☐
Yes
☐
☐
☐
☐
☐
No
☐
☐
☐
☐
☐
Please describe any musculoskeletal problems not mentioned above:
CARDIOVASCULAR:
Chest pain
Shortness of breath
Exercise intolerance
Swelling of feet
Swelling of hands
Yes
☐
☐
☐
☐
☐
No
☐
☐
☐
☐
☐
Palpitations
Faintness
Loss of consciousness
Calf pain with walking
Please describe any cardiovascular problems not mentioned above:
PULMONARY:
Cough
Sputum
Wheeze
Coughing up blood
Yes
☐
☐
☐
☐
No
☐
☐
☐
☐
Shortness of breath
Exercise intolerance
Smoking
Please describe any pulmonary problems not mentioned above:
GENERAL CONSTITUTIONAL:
Unexplained weight loss
Night sweats
Fatigue/malaise/lethargy
Change in sleep pattern
Change in appetite
Yes
☐
☐
☐
☐
☐
No
☐
☐
☐
☐
☐
Fever
Itch/rash
Recent trauma
Lumps/bumps/masses
Unexplained falls
Please describe any general constitutional symptoms not mentioned above:
2605 Harlem Road  Cheektowaga, New York 14225
Ph: (716) 891-2929  Fax: (716) 961-3767
Northtowns Neurology
Michael A. Meyer, MD
Patient Name:
5
Date of Birth:
GASTROINTESTINAL :
Abdominal pain
Unintentional weight loss
Difficulty swallowing:
Solids
Liquids
Indigestion
Bloating
Cramping
Yes
☐
☐
No
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Loss of appetite:
Nausea/vomiting
Diarrhea
Constipation
Vomiting blood
Bright red blood per rectum
Dark black tarry stools
Yes
☐
☐
☐
☐
☐
☐
☐
No
☐
☐
☐
☐
☐
☐
☐
Yes
☐
☐
☐
☐
☐
☐
☐
No
☐
☐
☐
☐
☐
☐
☐
Yes
☐
☐
☐
☐
☐
☐
☐
☐
☐
No
☐
☐
☐
☐
☐
☐
☐
☐
☐
Please describe any gastrointestinal symptoms not mentioned above:
SKIN AND BREAST:
Itching
Rash
Lesions
Wounds
Incisions
Nodules
Tumors
Yes
☐
☐
☐
☐
☐
☐
☐
No
☐
☐
☐
☐
☐
☐
☐
Eczema
Dryness
Discoloration
Breast pain
Soreness
Lumps
Discharge
Please describe any skin and breast symptoms not mentioned above:
ENDOCRINE:
Prefer cold weather
Prefer hot weather
Mood swings
Excessive sweating
Diarrhea
Constipation
Menstrual irregularity
Weight loss despite increased
appetite
Tremors
Palpitations
Yes
☐
☐
☐
☐
☐
☐
☐
No
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Visual disturbances
Slowness
Tiredness
Depression
Hair thinning
Dry skin
Headache
Excessive hunger
Frequent urination
Please describe any endocrinology symptoms not mentioned above:
2605 Harlem Road  Cheektowaga, New York 14225
Ph: (716) 891-2929  Fax: (716) 961-3767
Northtowns Neurology
Michael A. Meyer, MD
6
Patient Name:
Date of Birth:
HEMATOLOGIC :
Low blood count
Red spots on skin
Sickle cell family history
Prolonged or excessive bleeding
after dental extraction/injury
Family history of hemophilia
Yes
☐
☐
☐
No
☐
☐
☐
☐
☐
☐
☐
Use of anticoagulant and
antiplatelet drugs
(including aspirin)
Prior blood transfusion
Refused for blood donation
Night sweats
Yes
No
☐
☐
☐
☐
☐
☐
☐
☐
Please describe any hematologic symptoms not mentioned above:
ALLERGY AND IMMUNOLOGY:
“Difficulty breathing” or “choking
(anaphylaxis) with medication
or environmental allergies
Severe reaction to bee sting
Swelling or pain in groin, armpit or
neck (swollen lymph node/gland)
Allergic response (rash/itch)
Yes
No
☐
☐
☐
☐
☐
☐
☐
☐
Yes
No
Unusual sneezing
☐
☐
Runny nose
☐
☐
Itchy/teary eyes
☐
☐
Food, medication or environmental
allergy
☐
☐
Frequent infections
☐
☐
Please describe any allergic/immunologic symptoms not mentioned above:
GENITOURINARY:
Incontinence
Painful urination
Blood in urine
Frequent urination
during the day
during the night
Hesitancy
Decreased force of stream
Vaginal discharge
Yes
☐
☐
☐
No
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Vaginal pain
Irregular menses
Heavy or light menses
Early puberty
Early menopause
Oral contraceptive use
Depot injection use
Mirena IUD
Date of last pap smear and result:
Please describe any genitourinary complaint not mentioned above:
______________________________________
PATIENT SIGNATURE
___________
DATE
2605 Harlem Road  Cheektowaga, New York 14225
Ph: (716) 891-2929  Fax: (716) 961-3767
Yes
☐
☐
☐
☐
☐
☐
☐
☐
No
☐
☐
☐
☐
☐
☐
☐
☐