Duke Neurology at North Duke Street
New Patient Questionnaire
Name: _____________________ Date of Birth: ______________ Today’s Date: _____________
Reason for Visit: ________________________________________________________________
PAST MEDICAL HISTORY: (Please check conditions that you have been diagnosed with)
Anemia
CHF
High Cholesterol
Osteoporosis
Bleed in Brain
Arrhythmia
COPD
High Blood Pressure
Parkinson’s
Cancer
Arthritis
Dementia
Kidney Disease
Sarcoidosis
HIV/AIDS
Asthma
Depression
Migraine
Seizures
Hyrocephalus
Atrial Fibrillation Diabetes
Multiple Sclerosis
Sleep Apnea
Narcolepsy
Clotting Disorder Acid Reflux
Heart Attack
Stroke
Neuropathy
Brain Cancer
Glaucoma
Myopathy
Thyroid Disease Tremor
Other:
PAST SURGERIES:________________________________________________________________
______________________________________________________________________________
FAMILY HISTORY: (Indicate who has the condition: M = mother F = father S = Sibling C = Child)
Brain Aneurysm
Diabetes
Migraine
Parkinson’s
Cancer
Heart Attack
Multiple Sclerosis
Seizures
Clotting Disorder
High Cholesterol
Myopathy
Stroke
Dementia
High Blood Pressure
Neuropathy
Tremor
Other:
ALLERGIES and REACTION:_______________________________________________________
SOCIAL HISTORY:
Tobacco use: Never Current Former Packs per day _____ Number of Years______
Ready to quit smoking? Y N N/A
Alcohol use: Never Current Former Drinks per day _____
Street Drugs: Never Current Former Type: _____________________________
Education Level: _____________ Occupation: _________________ Marital Status ___________
Preferred Pharmacy Name: ___________________City________________Street:___________
CURRENT MEDICATIONS WITH DOSE AND FREQUENCY:
Duke Neurology at North Duke Street: Review of Systems
Constitution
Appetite Loss
Chills
Abnormal Sweating
Fever
Generalized Weakness
Fatigue
Night Sweats
Weight Gain
Weight Loss
HENT
Congestion
Ear discharge
Ear pain
Headaches
Hearing loss
Hoarseness
Nosebleeds
Painful Swallowing
Sore throat
Loud breathing
Ringing in ears
Gastrointestinal
Bloating
Abdominal pain
No appetite
Change in bowel habits
Bowel incontinence
Constipation
Diarrhea
Difficulty swallowing
Excessive appetite
Gas
Heartburn
Vomiting blood
Blood in stool
Hemorrhoids
Nausea/Vomiting
Eyes
Blurred Vision
Discharge
Double Vision
Pain
Light Sensitivity
Redness
Vision loss – left eye
Vision loss – right eye
Visual disturbance
Visual Halos
Cardiovascular
Chest Pain
Pain in legs with walking
Blue skin
Shortness of breath with walking
Irregular Heart Beat
Leg swelling
Light headed when standing
Shortness of breath lying flat
Heart fluttering
Waking with shortness of breath
Passing out
Genitourinary
Bladder incontinence
Sexual dysfunction
Painful urination
Flank pain
Genital sores
Blood in urine
Urinary hesitancy
Incomplete bladder empting
Heavy periods
Missed period
Waking to urinate at night
Vaginal bleeding
Pelvic pain
Increased urge to urinate
Please check off the symptoms you are currently experiencing
Respiratory
Cough
Coughing up blood
Shortness of breath
Sleep disturbance due to breathing
Snoring
Coughing up sputum
Wheezing
Endocrine
Intolerance of cold
Intolerance of heat
Always thirsty
Always hungry
Increased urination
Heme/Lymph
Swollen lymph nodes
Bleeding disorder
Easy bruising
Neurological
Loss of voice
Episodes of weakness
Concentration difficulty
Coordination disturbances
Daytime sleepiness
Dizziness
Focal weakness
Light-headedness
Loss of balance
Numbness
Tingling
Seizures
Sensory change
Tremors
Vertigo
Skin
Changes in nail beds
Discoloration
Dryness
Flushing
Itching
Poor wound healing
Rash
Skin Cancer
Suspicious moles/spots
Unusual hair distribution
Musculoskeletal
Arthritis
Back Pain
Falls
Gout
Joint pain
Joint swelling
Muscle cramps
Muscle weakness
Muscle pain
Neck pain
Stiffness
Psychiatric
Altered mental status
Depression
Hallucinations
Hyperactive
Insomnia
Memory loss
Anxiety
Substance abuse
Suicidal thoughts
Thoughts of violence
Allergy/Immuno
Seasonal allergies
HIV risk
Hives
Persistent infections