Initial Clinic Data Form Signature: Type or Draw × Type Mode On. Draw Mode On. Type It Draw It Clear South Atlanta Neurology & Spine Clinic, P.C. Initial Clinical Data Form Please fill out the following questionnaire as best as you can. This will help us evaluate your medical condition more effectively and thoroughly. Your cooperation will be greatly appreciated. Patient Name:DATE:Who referred you to our clinic (if no one, write “self-referral”)?Who is your primary care doctor? AGE:Which hand is dominant? Right Left Equal GENDER: M F Who is your primary care doctor? RACE: White African American Asian Indian Native American Hispanic Other Person filling out paperwork (if not patient)(relationship)Is your visit related to an accident or injury? Yes No If so (check one) Work Related Auto Other Have you been seen by a Neurologist or Pain Management in the past year? Yes No Have you been in the hospital recently? Yes No Did you bring any records, MRIs or CTs with you? Yes No **Please list the symptoms you are being seen for today (LIMIT 5 SYMPTOMS). List the symptoms highest priority to least. (Do not give details) 1:2:3:4:5:Are you currently experiencing any of the following symptoms that were not listed above? Please checkmark all that apply: Fever Weight loss Weight gain Fatigue Sleep disturbance Memory loss Sad feeling Hallucination Blurry vision Low back pain Double vision Swallowing difficulties Slurry Speech Headache Dizziness Hearing loss Ringing in the ears Sinus/nasal congestion Shortness of breath Chest pain Abdominal pain Nausea/vomiting Diarrhea Urinary incontinence Stool incontinence Changes in menstrual cycle Weakness Numbness Neck pain Arm pain Leg Pain PAST MEDICAL HISTORY: **If you have any of the following medical conditions, please circle them and write the year you were diagnosed with the conditions. Stroke Seizure Head Trauma Diabetes Arthritis Blood Disorder Blood Vessel Disorder Lung Disorder Asthma Emphysema Autoimmune Disorder Sinusitis Skin Disease High Cholesterol Heart Disease High Blood Pressure Heart Attack Kidney Disease Liver Disorder Stomach/GI Disease Sleep Disorder Depression Spine Disorder (type?) Cancer (type?) What type?What type? LIST ANY OTHER medical conditions that were not listed above List ANY surgeries you’ve previously had and the year they were preformed. List ANY medication you are currently taking (including vitamins and supplements), how often you take it, and the dose of the medication. Are you allergic to any medications? YES NO If so, what medications? SOCIAL HISTORYOccupation:Marital Status:Tobacco use: Previous use Current use Never If previous, when did you quit?If current, how often?Alcohol: Regular Social Occasional Rare Never Regular use: times per week.Any history of illegal drug use? Yes No If yes, what substances? current use past use experimented with FAMILY HISTORY: Do any of the following medical diseases affect any of your family members, not including yourself, spouse or step-parents? Circle them and list family member (F=Father M=Mother S=Sister ect.) Stroke Seizure Head Trauma Diabetes Arthritis Blood Disorder Blood Vessel Disorder Lung Disorder Asthma Emphysema Autoimmune Disorder Sinusitis Skin Disease High Cholesterol Heart Disease High Blood Pressure Heart Attack Kidney Disease Liver Disorder Stomach/GI Disease Sleep Disorder Depression Spine Disorder (type?) Cancer (type?) What type?What type?