ADULT AND PEDIATRIC NEUROSURGERY, P.C.
PETRA GURTNER, M.D.
PATIENT HEALTH HISTORY
Patient Name________________________________________________DOB________________________
Referred by:___________________________Primary Care Physician______________________________
Reason for Today’s Visit (Chief Complaint)___________________________________________________
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
_____Yes
Dose
Complications
_____No
Frequency
Allergies to Medications:__________________________________________________________________
FAMILY HISTORY
Family Member
Grandmother (Mom’s)
Grandfather (Mom’s)
Grandmother (Dad’s)
Grandfather (Dad’s)
Father
Mother
Sister/Brother
Sister/Brother
Alive/Deceased
A
D
A
D
A
D
A
D
A
D
A
D
A
D
A
D
Age
Health Status or Cause of Death
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Patient Name____________________________________________________________________________
SOCIAL HISTORY
Occupation:_____________________________________________________________________________
Marital Status: ___Single ___Married ___Separated ___Divorced ___Widowed
Do you have children: ____No
____Yes
Do you live alone? _____No ____Yes
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_____________________________ Yes/No
Excessive Fatigue__________________ Yes/No
Weight Loss______________________ Yes/No
Night Sweats_____________________ Yes/No
EYES
Infections__________________________ Yes/No
Glaucoma__________________________ Yes/No
Wear Glasses_______________________ Yes/No
Injuries___________________________ Yes/No
Cataracts_________________________ Yes/No
Date of Last Eye Exam_____________________
EARS, NOSE, THROAT AND MOUTH
Wear Hearing Aids___________________ Yes/No---------Date of Last Exam_________________________
Hearing Loss_______________________ Yes/No
Ear Pain__________________________ Yes/No
Ear Infections_______________________ Yes/No
Ringing in Ear (Right/Left)___________ Yes/No
Balance Disturbances (e.g., Vertigo,
Nasal Drainage____________________ Yes/No
Spinning_____________________ Yes/No
Amount_________Color_______
Nose Bleeds________________________ Yes/No
Nasal Congestion__________________ Yes/No
Inability to Smell_____________________Yes/No
Sinus Problems____________________ Yes/No
Sinus Headaches____________________ Yes/No
Sore Throat_______________________ Yes/No
Mouth Sores________________________ Yes/No
CARDIOVASCULAR
High Blood Pressure_________________ Yes/No
Heart Murmur_______________________ Yes/No
Swelling in Feet or Hands_____________ Yes/No
Chest Pain or Angina_________________ Yes/No
Irregular Pulse_____________________ Yes/No
High Cholesterol___________________ Yes/No
Leg Pain While Walking_____________ Yes/No
Date of last EKG___________________________
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Patient Name____________________________________________________________________________
RESPIRATORY
Asthma_____________________________ Yes/No
Emphysema__________________________Yes/No
Bronchitis____________________________Yes/No
Lung Cancer__________________________Yes/No
Date of Last Chest X-ray_______________________
GASTROINTESTINAL
Indigestion or Pain w/Eating____________ Yes/No
Vomiting_____________________________ Yes/No
Liver Disease_________________________Yes/No
Abdominal Pain_______________________Yes/No
Ulcers or Gastritis_____________________Yes/No
GENITOURINARY
Urinary Tract Infections_________________Yes/No
Blood In Your Urine____________________Yes/No
Incontinence__________________________Yes/No
Prostate Cancer (males)________________Yes/No
Uterine or Cervical Cancer (females)______Yes/No
MUSCULOSKELETAL
Arm or Leg Weakness__________________Yes/No
Arm or Leg Pain_______________________Yes/No
Arthritis______________________________Yes/No
Chronic Cough___________________
Shortness of Breath_______________
Pneumonia______________________
Bloody Sputum___________________
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
Painful Urination__________________Yes/No
Difficulty Starting or Stopping Stream_Yes/No
Kidney Stones____________________Yes/No
Endometriosis____________________Yes/No
Back Pain________________________Yes/No
Joint Pain or Swelling______________Yes/No
Broken Bones____________________Yes/No
List:___________________________________
INTEGUMENTARY
Skin Disease_________________________ Yes/No
Nipple Discharge (females)_____________ Yes/No
Skin Cancer_____________________ Yes/No
Breast Pain, Tenderness/Swelling
(females)____________________ Yes/No
Date and Results of Last Mammogram (females)________________________________________
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
Seizures________________________ Yes/No
Disorientation___________________ Yes/No
Inability to Concentrate___________ Yes/No
Face Weakness__________________ Yes/No
PSYCHIATRIC
Anxiety______________________________ Yes/No
Depression_____________________ Yes/No
Other Psychiatric Disorder or Treatment_____________________________________________________
ENDOCRINE
Diabetes_______________________________ Yes/No
Increased Appetite______________________ Yes/No
Excessive Thirst or Urination_____________ Yes/No
Thyroid Disease_________________ Yes/No
Hormone Problems______________ Yes/No
HEMATOLOGIC/LYMPHATIC
Anemia________________________________ Yes/No
Hemophilia____________________
Yes/No
Bleeding Tendencies_____________________ Yes/No
Persistant Swollen Glands or Lymph
Blood Transfusion_______________________ Yes/No
Nodes______________________
Yes/No
If yes, when?___________________________________________
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PATIENT NAME__________________________________________________________________________
ALLERGIC/IMMUNOLOGIC
Food Allergies____________________________ Yes/No-------List_________________________________
Inhalant (Nasal) Allergies___________________ Yes/No-------List_________________________________
Immunologic Disorders____________________ Yes/No
THE ABOVE INFORMATION IS ACCURATE TO THE BEST OF MY KNOWLEDGE.
________________________________________________
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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