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Neurological History Information Sheet

If you prefer, you can print this form, fill it out and deliver it to the office.

Please only complete if you have a neurology appointment
Please complete all fields. If there is no answer or the question doesn't apply to you, please enter "None" or "N/A".

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Have you ever seen a neurologist before?
Have you ever taken neurological medications before? If so, please list.
Click on the '+' sign to add more medications
Medication/Length of time taken
Did it help
Side effects (if any)
 
Do you feel you have any memory problems or other cognitive disorder?

Family History

Please check all that apply
Cancer
Diabetes
Heart Disease
Hypertension
Depression
Anxiety
Bipolar
Dementia
Schizophrenia
Substance Abuse
Parkinson's
Epilepsy/seizures
Multiple Sclerosis

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