RAFAEL YAKUTILOV NEUROLOGY, PC
15 Beach 105th Street, Rockaway Park, NY 11694
Tel: 718-474-0023 Fax: 718-474-2033
Neurology Questionnaire
Name: _______________________________________________
Date: ____________________
Age: _______ Gender_____________________
Height: _________
Weight:_____________
Right Handed? ___
Left Handed? ____
Both? ____
Occupation: ______________________
MEDICATIONS: List all medications you are taking at the present time
Name and strength
Frequency
Reason for medication
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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Allergies:_____________________________________________________________________________
Reason for visit today___________________________________________________________________
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Significant Past Medical History/ Conditions: Serious illness and/or operations. Please Circle:
Alcoholism
Alzheimer's
Anemia or Blood problems
Aneurysm
Anorexia
Anxiety
Appendicitis
Arthritis
Asthma
Bell's palsy
Breast Lump
Brain Surgery
Brain Tumor
Bronchitis
Bulimia
Cancer
Cardiac disease
Carpal Tunnel
Cataracts
Chemical Dependency
COPD
Chicken Pox
Chronic Pain
Chronic Bronchitis
Cosmetic Surgery
C-Section
Depression
Diabetes
Emphysema
Epilepsy
Fainting
Fibromyalgia
Gallbladder Surgery
Glaucoma
Goiter
Gonorrhea
Gout
Head Injury
Headaches
Heart Attacks
Heart Disease
Heart Surgery
Hepatitis
Hernia
Herpes
High Cholesterol
Hip Replacement
HIV Positive
Hypertension
Hysterectomy
Irregular heart beat
Joint Repair
Kidney Disease
Knee Replacement
Liver Disease
Lung Disease
Lupus
Mastectomy
Multiple Sclerosis
Meningitis
Pacemaker
Parkinson's Disease
Pneumonia
Polio
Prostate Surgery
Pulmonary embolus
Rheumatic Fever
Scarlet Fever
Seizures
Sleep Apnea
Spinal Surgery
Stroke
Suicide Attempt
Syncope
Thyroid Problems
TIAs
Tonsillitis
Transfusions
Tremors
Tuberculosis
Typhoid Fever
Ulcers
Vaginal Infections
Venereal Disease
Other:_______________________________________________________________________________
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Do you now or have you had any problems WITHIN THE PAST YEAR related to the following
symptoms: Please Circle.
General
Fever/chills
Night sweats
Weight changes
Changes in sleeping habits
Fatigue
Psychiatric
Anxiety
Depression
Psychosis
Panic attacks
Loss of initiative
Depression
Crying
Loss of interest
Hallucinations
Hearing voices
Paranoia
Delusions
Racing thoughts
Easily distracted
HEENT
Ringing in the ears
Ear pain
Hearing difficulties
Enlarged tonsils
Head trauma
Jaw pain
Change in smell
Change in voice
Difficulty swallowing
Loss of vision
Glasses
Double vision
Visual loss
Glaucoma/Cataracts
Gastrointestinal
Nausea/vomiting
Stool changes
Abdominal pain
Constipation/Diarrhea
Excessive hunger/thirst
Rectal bleeding
Loss of appetite
Liver problems
Cirrhosis
Hepatitis
Sleep
Snoring
Pausing in breath while sleeping
Insomnia
arousals with choking or gasping
Excessive day time sleepiness
Drowsy while driving
Poor sleep
Recurrent arousals
Trouble falling asleep
Can't stay asleep
Cardio
Chest pains
Palpitations
Atrial Fibrillation
Fainting
Irregular heartbeats
High blood pressure
Heart disease/surgeries
Murmur
Swelling of Ankles
Pacemaker
Exertional chest pain
Heart attack (year __________)
CHF heart failure
Skin
Rashes
Skin changes
Genitourinary
Urinary frequency
Blood in urine
Incontinence
Sphincter changes
Male
Erectile dysfunction
Prostate problems
Female
Abnormal Pap Smear
Excessive Periods
Breast lump
Hysterectomy/ C-Section
Miscarriages
Musculoskeletal
Neck pain/stiffness
Lower back pain/sciatica
Muscle/joint pain
Fractures/sprains
Limited movements
Arthritis
Skeletal deformities
Joint pain
Osteoarthritis
Rheumatoid arthritis
Osteoporosis
Endocrinology
Diabetes
Thyroid problems
High triglycerides
Hematology
Anemia
Leukemia
Blood clotting problems
Swollen glands
Easy bruising
Respiratory
Wheezing/Coughing
Shortness of breath
Other:_______________________________________________________________________________
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Neurological
Weakness in the limbs
Speech problems
Tingling or numbness in the hands/feet
Occasional weakness on one side of the body
Sensory loss on one side of the body
Occasional visual loss in one eye
Seizures/ convulsions
Febrile seizures in childhood
Loss of consciousness
Trance states, derealization
Loss of balance
Head injury/ concussion
Back injury _________________ months ago
Lower back pain radiating to the R / L / Both leg(s)
Neck injury ________ months ago
Neck pain radiating to R / L / Both arm(s)
Weakness (Where?________________)
Muscle cramps
Tremor
Involuntary movements
Tics
Widespread aches and pains
Chronic fatigue
Motor vehicle accident (When?________)
Dizziness/ Lightheaded/ Spinning
Fainting spells/ Syncope
Getting lost/ wandering
Forgetting to turn off the gas
Losing money
Memory loss
Forgetting family names
Swallowing problems
Wetting yourself
Bed wetting
Soiling clothing
Light sensitivity
Nausea with headache
Sees flashing lights before headaches
Headaches:
How long?_____________________________________________________________________
How often?_____________________________________________________________________
How frequent?__________________________________________________________________
Rate your pain on a scale from 1 to 10, 1 being the least severe and 10 being most severe______________
Pain:
Where?________________________________________________________________________
How often?_____________________________________________________________________
How frequent?__________________________________________________________________
Rate your pain on a scale from 1 to 10, 1 being the least severe and 10 being most severe______________
Other:_______________________________________________________________________________
_____________________________________________________________________________________
FAMILY HISTORY:
Mother: Living____Yes_____No_____Age:____Health________________________________________
Father: Living____Yes_____No_____Age:____ Health_______________________________________
Siblings:Number____Ages__________________ Health_______________________________________
SOCIAL HISTORY:
Marital status: Single________Married_________Widowed _________Domestic Partner____________
Do you smoke? ______________________
Do you drink alcohol?_________________
Do you use recreational drugs?__________
If yes type/amount/how long:______________________
If yes type/amount/how long:______________________
If yes type/amount/how long:______________________
I undersigned hereby authorize Dr. Rafael Yakutilov to render treatment to myself that he deems medically
necessary in order to treat the condition or the conditions I have requested from himself and the staff. I acknowledge
that I was provided a copy of the HIPPA notice of privacy practices that I have read (or had the opportunity to read
if so chose) and understood the notice.
Signature:_________________________________________________ Date:___________________
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