Neurosurgery Group HEALTH HISTORY Date: ______

Neurosurgery Group HEALTH HISTORY Date: ______1010 East Third Street Suite 202 Chattanooga, TN 37403  Ph: (423) 265-2233  Fax: (423) 756-8265

All information is treated as strictly confidential. The more fully you complete this form, the better we will be able to diagnose and treat you. Name: ______DOB: ______Age: ______

Office Use Only: Temp______HR______BP______RR______HT______WT______BMI______CHIEF COMPLAINT (Why are you seeing doctor today? ) ______Location of Pain: □ Head □ Neck □ Back □ Other ______Date Started: ______Does the Pain extend into your □ ARMS or □ LEGS? □ Yes □ No How bad is your pain on a scale of 1-10 (1 = minimal & 10 = worst) At its Best: ______At its Worst: ______What makes it - Better______Worse______Have you been treated with: □ Physical Therapy □ Chiropractor □ Pain Management □ NSAIDS (Advil/Aleve)

CURRENT AND PAST MEDICAL PROBLEMS □ Hypertension □ Diabetes □ Osteoporosis ______

SURGERIES YEAR ANY COMPLICATIONS ______

MEDICAL ALLERGIES ALLERGY SYMPTOMS ______

CURRENT MEDICATIONS (RX or OTC) STRENGTH / DOSAGE (attach list for numerous meds) ______Blood Thinner’s? ______

SOCIAL HISTORY Occupation: ______Marital Status: □ Single □ Married □ Divorced □ Widow Children: □ Yes □ No How Many? ______Do you Smoke? □ Yes □ No □ Quit ______how long □ Never Smoked □ Cigarettes ______packs per day for ______year’s □ Cigars/Pipe □ Smokeless Tobacco Do you drink Alcohol? □ Never □ Rarely □ Socially □ Regularly FAMILY HISTORY Alive Age Medical Problems Deceased Cause of Death Father □ ______□ ______Mother □ ______□ ______Sister/Brother □ ______□ ______

1 Sister/Brother □ ______□ ______MEDICAL REVIEW Current Past Current Past * Check all that apply * Problem Problem Problem Problem Allergy / Immunological Heart Asthma □ □ Last EKG ______□ □ Hives □ □ Chest Pain □ □ Immune Deficiency □ □ High Blood Pressure □ □ Swelling □ □ Leg Pain when walking □ □ Constitutional / General Body Musculoskeletal Excessive Fatigue □ □ Muscle Ache □ □ Fever □ □ Weakness □ □ Weight Gain □ □ Fatigue □ □ Weight Loss □ □ Spasms □ □ Ear, Nose, Throat, & Mouth Neurological Balance Problems □ □ Blackout spells □ □ Ear Pain □ □ Seizures □ □ Hearing Loss □ □ Coordination Trouble □ □ Inability to Smell □ □ Double/Blurred Vision □ □ Nosebleeds □ □ Facial Weakness □ □ Ringing of Ears □ □ Speech Difficulty □ □ Eyes Psychiatric Cataracts □ □ Bipolar □ □ Glaucoma □ □ Depression □ □ Injuries □ □ Psychiatric Treatment □ □ Vision Loss □ □ Respiratory Endocrine Last Chest X-ray ______Diabetes Type I □ □ Oxygen Use □ □ Diabetes Type II □ □ CPAP Use □ □ Excessive Thirst □ □ Asthma □ □ Excessive Urination □ □ Bronchitis □ □ Hormone Problems □ □ COPD □ □ Thyroid Problems □ □ Emphysema □ □ Gastrointestinal Lung Cancer □ □ Abdominal Pain □ □ Pleurisy □ □ Blood in Stool □ □ Pneumonia □ □ Blood in Vomit □ □ Shortness of Breath □ □ Colon Cancer □ □ Skin / Integumentary Constipation □ □ Last Mammogram ______Jaundice □ □ Breast Disorder □ □ Liver Disease □ □ Easy Bruising □ □ Nausea □ □ Skin Cancer □ □ Vomiting □ □ Skin Ulcers □ □ Ulcers □ □ Sores or Abscesses □ □ Hematology / Blood Disorder Thin Skin □ □ Anemia □ □ Free Bleeder □ □ Any Other Types Cancer Genitourinary Bladder Infections □ □ ______Blood in Urine □ □ Incontinence □ □ Kidney Stones □ □ Any Types of Stents Trouble Starting/Stopping □ □ Stream of Urine ______Prostate Cancer □ □ UTI □ □ Uterine/Cervical Cancer □ □

The above information is accurate to the best of my knowledge. PATIENT SIGNATURE: ______DATE: ______I have reviewed the information with the patient. PHYSICIAN SIGNATURE: ______DATE: ______

2 revised 9-15-16