Neurology Questionnaire

Neurology Questionnaire

Note: this entire form must be completed in one sitting. Please allow yourself at least 30 minutes to complete.
Patient Name *

First Name Middle Initial Last Name
Date of Birth *

Month Day Year
Age *
Gender *

Male Female
Preferred language: *
Referring Physician Name *
Are you right-handed, left-handed or ambidextrous? *

Right-handed Left-handed Ambidextrous
Please explain the reason for your neurology visit: *
Do you have any past medical history? *

Yes No
Please list OR upload a file. Please list ALL past medical history:
Upload any past medical history

Cancel of
Have you had ANY previous surgeries, hospitalizations, or other significant in-patient healthcare events? *

Yes No
Please list OR upload a file. Please list ALL previous surgeries, hospitalizations, or other significant in-patient healthcare events:
Attach any hospitalizations & operations

Cancel of
Have you had any injuries (include any episodes of loss of consciousness)? *

Yes No
Please list injuries *
Have you had a blood transfusion(s)? *

Yes No
Please list transfusion(s) *
Are you allergic to any medication(s), food(s), or have any environmental allergies? *

Yes No
Please list allergies (medication/food/seasonal/other) *
Do you have any current and/or recent medication(s)? *

Yes No
Please list OR upload a file. Please list ALL your current and/or recent medication(s) with dosages, and times taken each day:
Upload an updated current and/or recent medication list from your provider(s) or Pharmacy

Cancel of
Do you take any dietary supplement(s) and vitamin(s)? *

Yes No
Please list ALL your dietary supplement(s) and vitamin(s) with dosage(s), and how often:
Social History
Any use of tobacco products? (Including smoking, vaping, and or chewing tobacco) *

Yes No
Please list tobacco products below: *
Any use of alcohol? *

Yes No
Please fill out history of drinking alcohol. Types of alcohol include, but are not limited to: wine, beer, liquor, etc. You do not need to be specific with the brand or sub-class of alcohol. *
Any use of recreational drugs? *

Yes No
Please fill out recreational drugs *
Are you exposed to toxins/poisonous substances at work or with hobbies *

Yes No
Please explain exposure: *
Are you employed? *

Yes No
Name of employer and occupation *
Education: *

Grade School High School College Post-Graduate Voc. Training
Other specification of employer
Marital status: *

Single Married Divorced Separated Widowed
Birthplace: *
Family History
Does your biological mother have any previous health problems? *

Yes No Unsure
Mother's name: *
Does your biological father have any previous health problems? *

Yes No Unsure
Father's information: *
Do you have any siblings? *

Yes No
List sibling(s) information: *
Do you have any children? *

Yes No
List children(s) information: *
Please mark all the symptoms that apply:

Have any of your family had the following conditions? If yes whom? *

Write Whom

Heart disease

Stroke

High blood pressure

Fainting/Syncope

High cholesterol

Diabetes

Dementia

Cancer

Epilepsy/seizures

Multiple Sclerosis

Parkinson’s

Polio

Mental disease

Foot drop

Muscular Distrophy

Thyroid disease

Inflammatory Myositis

Hashimoto Thyroiditis

Hereditary Neuropathy

Rheumatoid Arthritis

Scleroderma

Lupus (SLE)

Lymphoma

Sjogren’s Syndrome

Celiac (Gluten Sensitivity)

Adrenoleukodystrophy

Essential Tremor

ALS

Genetic Disorder

Cerebellar Ataxia

Kidney Stones

Brain Tumor

Scoliosis

Liver Disease

Cardiomyopathy

Mental Retardation

Cerebral Aneurysm

Substance Abuse

Congestive Heart Failure

None of the above

Review Systems

Please place a checkmark if you currently have any of the following symptoms
Constitutional *

Fever Weight loss Fatigue None of the above
Ear/Nose/Throat *

Trouble hearing Ringing in ear(s) Dizziness (Vertigo) Loss of balance Ear pain Ear discharge None of the above
Cardiovascular *

Chest pain Irregular heartbeat Limb swelling Fast heartbeat Pain on walking Fainting None of the above
Respiratory *

Trouble breathing Chronic cough Limb swelling Coughing blood None of the above
Gastrointestinal *

Indigestion Heart burn Abdominal pain Nausea Vomiting Regurgitation Diarrhea Constipation Bloody stools None of the above
Genitourinary *

Incontinences Pain on urination Blood in urine None of the above
Musculoskeletal *

Muscle pain Muscle cramp Muscle twitches Neck pain Low back pain Joint pain Joint stiffness Joint swelling None of the above
Skin & Breast *

Skin rash Skin discoloration None of the above
Neurologic *

Numbness Tingling Headache/face pain Face numbness Weakness Blackouts Trouble with memory Clumsiness None of the above
Psychiatric *

Hallucinations Feeling depressed Inappropriate crying Anxiety Problems sleeping Suicidal thoughts Inappropriate laughing None of the above
Hematologic/Lymphatic *

Abnormal bleeding Nose bleeds Lumps or swelling None of the above
Allergic/Immunologic *

Skin rash Dry eyes Dry mouth None of the above
Endocrine *

Excessive thirst Heat or cold intolerance Excessive urination None of the above
Is the patient completing this questionnaire? *

Yes No
Name of person completing questionnaire *
Relationship to patient *
Patient/ Guardian signature *

Clear
Date signed *

Month Day Year
Date
Please verify that you are Human *
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8550 Cuthills Circle Lincoln, NE 68526 | alivation.com | info@alivation.com

Behavioral Health | Phone: 402.476.6060 | Fax: 402.476.6809

Primary Care | Phone: 402.466.3355 | Fax: 402.466.3410
Should be Empty:

Neurology Questionnaire

Social History

Family History

Please mark all the symptoms that apply:

Review Systems