ADULT AND PEDIATRIC NEUROSURGERY, P.C.
PETRA GURTNER, M.D., TINA RODRIGUE, M.D.
PATIENT HEALTH HISTORY
Patient Name: ______________________________________________ DOB: ________________________
Referred by: ____________________________ Primary Care Physician: ___________________________
Reason for Today’s Visit (Chief Complaint):___________________________________________________
Height: _____________________________________ Weight: ____________________________________
Is your current problem the result of an injury? Please check below all that apply:
_____ Car Accident
_____ Work Accident
_____ Other Accident
PAST MEDICAL HISTORY
Please list any prior major illnesses and/or injuries: ____________________________________________
Surgeries/Hospitalizations
Year
Have you ever had any problems with anesthesia?
Current Medications
Complications
_____Yes
Dose
_____ No
Frequency
Allergies to Medications: __________________________________________________________________
FAMILY HISTORY
Family Member
Alive/Deceased
Grandmother (Mom’s)
Grandfather (Mom’s)
Grandmother (Dad’s)
Grandfather (Dad’s)
A
A
A
A
D
D
D
D
Father
A
D
Mother
A
D
Sister/Brother
A
D
Sister/Brother
A
D
Age
Health Status or Cause of Death
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ADULT AND PEDIATRIC NEUROSURGERY, P.C.
PETRA GURTNER, M.D., TINA RODRIGUE, M.D.
PATIENT HEALTH HISTORY
Patient Name: ______________________________________________ DOB: ________________________
SOCIAL HISTORY
Occupation: _____________________________________________________________________________
Marital Status:
___ Single
Do you have children:
___ Married
___ No
Do you live alone?: ___ No
___ Yes
___ Yes
___ Separated
____ Divorced
___ Widowed
How Many?: ____________________________________
Who lives with you?: _____________________________
Do you smoke cigarettes?
_____ No, I have never smoked cigarettes.
_____ No, I quit ____ years ago. At that time I was smoking __ pks per day for ____ years.
_____ Yes, I smoke____ packs of cigarettes per day for ____ years.
Do you smoke cigars or a pipe?
__ No
___ Yes
How often? _______ How many years? ________
Do you drink alcohol?
____ No, never (or rarely).
____ No, but I used to. Explain: _________________________________________________
____ Yes. If yes, how often?
____ Daily
____ 1 or more times a week.
_____ 1 or more times a month.
Are you at risk for AIDS (e.g., sexual orientation, drug abuse, previous blood transfusion)?
____ No
___ Yes.
Please Explain: ______________________________________________
REVIEW OF SYSTEMS
Are you currently, or have you ever had problems with:
(Circle Yes or No)
CONSTITUTIONAL
Fever ___________________________
Excessive Fatigue ________________
Yes/No
Yes/No
Weight Loss ____________________
Night Sweats ___________________
EYES
Infections _______________________
Glaucoma _______________________
Wear Glasses ____________________
Yes/No
Yes/No
Yes/No
Injuries ________________________
Yes/No
Cataracts ______________________
Yes/No
Date of Last Eye Exam _____________________
Yes/No
Yes/No
Yes/No
Ear Pain _______________________
Yes/No
Ringing in Ear (Right/Left) ________
Yes/No
Nasal Drainage __________________
Yes/No
Amount ________ Color________
Nasal Congestion _______________
Yes/No
Sinus Problems _________________
Yes/No
Sore Throat ____________________
Yes/No
Date of Last Exam _________________________
EARS, NOSE, THROAT AND MOUTH
Wear Hearing Aids ________________
Hearing Loss ____________________
Ear Infections ____________________
Balance Disturbances (e.g., Vertigo)
Spinning __________________
Nose Bleeds _____________________
Inability to Smell _________________
Sinus Headaches _________________
Mouth Sores _____________________
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
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Yes/No
Yes/No
ADULT AND PEDIATRIC NEUROSURGERY, P.C.
PETRA GURTNER, M.D., TINA RODRIGUE, M.D.
PATIENT HEALTH HISTORY
Patient Name: ______________________________________________ DOB: ________________________
CARDIOVASCULAR
High Blood Pressure ______________
Heart Murmur ____________________
Swelling in Feet or Hands __________
Chest Pain or Angina _____________
Yes/No
Yes/No
Yes/No
Yes/No
Irregular Pulse __________________
Yes/No
High Cholesterol ________________
Yes/No
Leg Pain While Walking __________
Yes/No
Date of last EKG __________________________
RESPIRATORY
Asthma _________________________
Yes/No
Emphysema _____________________
Yes/No
Bronchitis _______________________
Yes/No
Lung Cancer _____________________
Yes/No
Date of Last Chest X-ray ____________________
Chronic Cough __________________
Shortness of Breath _____________
Pneumonia _____________________
Bloody Sputum _________________
Yes/No
Yes/No
Yes/No
Yes/No
GASTROINTESTINAL
Indigestion or Pain w/Eating________
Vomiting ________________________
Liver Disease ____________________
Abdominal Pain __________________
Ulcers or Gastritis ________________
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Nausea ________________________
Blood in Your Vomit _____________
Jaundice _______________________
Change in your Bowel Habits ______
Colon Cancer ___________________
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
GENITOURINARY
Urinary Tract Infections ___________
Blood in Your Urine _______________
Incontinence_____________________
Prostate Cancer (males) ___________
Uterine or Cervical Cancer (females) _
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Painful Urination ________________
Difficulty Starting or Stopping Stream
Kidney Stones __________________
Endometriosis __________________
Yes/No
Yes/No
Yes/No
Yes/No
MUSCULOSKELETAL
Arm or Leg Weakness _____________
Arm or Leg Pain __________________
Arthritis _________________________
Yes/No
Yes/No
Yes/No
Back Pain ______________________
Yes/No
Joint Pain or Swelling ____________
Yes/No
Broken Bones __________________
Yes/No
List: ___________________________________
INTEGUMENTARY
Skin Disease_____________________
Nipple Discharge (females)_________
Yes/No
Yes/No
NEUROLOGICAL
Fainting Spells or “Black Outs” _____
Problems with your Memory________
Difficulty with your Speech_________
Double or Blurred Vision __________
Coordination in Arm and/or Legs____
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Skin Cancer ____________________
Yes/No
Breast Pain, Tenderness/Swelling
(females) _________________
Yes/No
Date and Results of Last Mammogram (females) _______________________________________________
Seizures _______________________
Disorientation __________________
Inability to Concentrate ___________
Face Weakness _________________
Yes/No
Yes/No
Yes/No
Yes/No
PSYCHIATRIC
Anxiety _________________________
Yes/No
Depression _____________________
Yes/No
Other Psychiatric Disorder or Treatment _____________________________________________________
-3-
ADULT AND PEDIATRIC NEUROSURGERY, P.C.
PETRA GURTNER, M.D., TINA RODRIGUE, M.D.
PATIENT HEALTH HISTORY
Patient Name: ______________________________________________ DOB: ________________________
ENDOCRINE
Diabetes ________________________
Increased Appetite________________
Excessive Thirst or Urination _______
Yes/No
Yes/No
Yes/No
Thyroid Disease _________________
Hormone Problems ______________
Yes/No
Yes/No
HEMATOLOGIC/LYMPHATIC
Anemia _________________________
Yes/No
Bleeding Tendencies ______________
Yes/No
Blood Transfusion ________________
Yes/No
If yes, when? _____________________________
Hemophilia _____________________
Persistent Swollen Glands or Lymph
Nodes ___________________
Yes/No
ALLERGIC/IMMUNOLOGIC
Food Allergies ___________________
Inhalant (Nasal) Allergies __________
Immunologic Disorders____________
List _____________________________________
List _____________________________________
Yes/No
Yes/No
Yes/No
Yes/No
THE ABOVE INFORMATION IS ACCURATE TO THE BEST OF MY KNOWLEDGE.
______________________________________________
PATIENT SIGNATURE
___________________________________
DATE
______________________________________________
PATIENT SIGNATURE
___________________________________
DATE
______________________________________________
PATIENT SIGNATURE
___________________________________
DATE
I HAVE REVIEWED THE ABOVE INFORMATION WITH THE PATIENT.
______________________________________________
PHYSICIAN SIGNATURE
___________________________________
DATE
______________________________________________
PHYSICIAN SIGNATURE
___________________________________
DATE
______________________________________________
PHYSICIAN SIGNATURE
___________________________________
DATE
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