STROKE CLINIC QUESTIONNAIRE
PLEASE COMPLETE AND BRING WITH YOU TO YOUR APPOINTMENT
Name: _______________________________________
Date: ___________
If you are seeing one of our physicians for the first time, we would appreciate you answering the following
questions. This will give us a clear picture of your overall health, and allow your doctor to help you better with
your neurological problem.
REASON FOR VISIT
What is the complaint or problem you are having? ________________________________________________
When did this problem begin? _________________ Is this a NEW or OLD problem? ____________________
Were you hospitalized? If YES, when and where were you hospitalized? ______________________________
Have you seen any doctors for this problem? _______ If YES, who did you see?
________________________
Did a doctor refer you to see us? If yes, who referred you? ________________________________________
Primary care doctor: Name ________________________________ Phone ____________________________
Other providers: Specialty ___________________ Name___________________ Phone__________________
Other providers: Specialty ___________________ Name___________________ Phone__________________
Pharmacy: _______________________________ Phone __________________ Location _______________
PERSONAL/SOCIAL HISTORY
DOB __________
Height _________
Are you currently employed? Yes/No
Highest Level of Education_______________
Occupation ___________________________
Wt ____________
Marital Status
 Single
 Married
 Divorced
 Widowed
Diet and Exercise History
How many SERVINGS of fruit and vegetables
do you eat daily?_____________________
Tobacco, Alcohol, and Drug History
Do you smoke tobacco? Yes/No
Smoke in past? Yes/No Quit when?___
If YES, how many years? ___________
If YES, how many packs/day? _______
Do you drink alcohol? Yes/No
If YES, how often? ________________
If YES, how many drinks/day? _______
How many DAYS per week do you exercise for
Do you do drugs? Yes/No
at least 30 minutes? ___________________
If YES, how often? ________________
If YES, which drugs? ______________
MEDICATIONS (Please list all medications you are currently taking including over the counter medications;
and/or bring all of your medication bottles with you)
Please list any allergies to medications ________________________________________________________
Name______________________________ Dosage_____________ Times per day_____________
Name______________________________ Dosage_____________ Times per day_____________
Name______________________________ Dosage_____________ Times per day_____________
Name______________________________ Dosage_____________ Times per day_____________
Name______________________________ Dosage_____________ Times per day_____________
Name______________________________ Dosage_____________ Times per day_____________
Name______________________________ Dosage_____________ Times per day_____________
PAST MEDICAL HISTORY: (Do you currently have, or were told you had any of the following problems?)
TIA (Transient ischemic attack)
Yes/No
Stroke
Yes/No
High blood pressure (Hypertension)
Yes/No
High cholesterol
Yes/No
Diabetes (Elevated blood sugar)
Yes/No
Myocardial infarction (Heart attack)
Yes/No
Blockage in Carotid artery (stenosis)
Yes/No
Patent Foramen Ovale (PFO)
Yes/No
Atrial fibrillation
Yes/No
Congestive heart failure
Yes/No
Arterial dissection (tear in the artery)
Yes/No
Sickle Cell disease
Yes/No
Moyamoya disease
Yes/No
Autoimmune disorder (Lupus)
Yes/No
Clotting Disorder
Yes/No
Genetic Disorder
Yes/No
FAMILY HISTORY
Member
Alive?
Mother
Y/N
________
Medical Problems or Cause of Death
________________________________________________________
Father
Y/N
________
________________________________________________________
Siblings
Y/N
________
________________________________________________________
Age Now
or at Death
REVIEW OF SYSTEMS/GENERAL MEDICAL PROBLEMS: (Do you currently have any of the following
problems? Check all problems below.)
General Problems
 Weight loss or gain
 Fatigue
 Fever or chills
 Weakness
 Trouble sleeping
Skin Problems
 Rashes
 Itching
 Dryness
 Color changes
Head and Neck
 Headache
 Head injury
 Neck Pain
Ears/Eye Problems
 Decreased hearing
 Ringing in ears
 Vision Loss/Changes
 Glasses or contacts
 Blurry or double vision
 Flashing lights
 Glaucoma
 Cataracts
Breast Problems
 Lumps
 Pain
Respiratory Problems
 Cough
 Sputum
 Coughing up blood
 Shortness of breath
 Wheezing
 Painful breathing
Cardiovascular Problems
 Chest pain or discomfort
 Tightness
 Palpitations
 Shortness of breath with
activity
 Difficulty breathing lying
down
 Swelling in legs
 Sudden awakening from
sleep with shortness of
breath
Gastrointestinal Problems
 Swallowing difficulties
 Heartburn
 Nausea
 Change in bowel habits
 Rectal bleeding
 Constipation
 Diarrhea
Urinary Problems
 Frequency
 Urgency
 Burning or pain
 Blood in urine
 Incontinence
Vascular Problems
 Calf pain with walking
 Leg cramping
Musculoskeletal
Problems
 Muscle or joint pain
 Stiffness
 Back pain
 Redness of joints
 Swelling of joints
 Trauma
Blood Problems
 Ease of bruising
 Ease of bleeding
Endocrine Problems
 Head or cold intolerance
 Sweating
 Frequent urination
 Thirst
 Change in appetite
Neurologic Problems
 Migraine
 Dizziness
 Fainting
 Seizures
 Weakness
 Numbness
 Tingling
 Tremor
 Poor coordination
 Slurred speech
 Loss of sensation
 Problems speaking
 Problems walking
 Abnormal movements
Psychiatric Problems
 Nervousness
 Stress
 Depression
 Memory loss
Signature _____________________________________ Date__________________________