Initial Clinic Data Form

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.

 Right  Left  Equal 
 M  
 
White  
African American  
Asian  
Indian  
Native American  
Hispanic  
Other 


 Yes  No 
 Work Related  Auto  Other 
 Yes  No 
 Yes  No 
 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)


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?) 

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.

 YES  NO 


 Previous use  Current use  Never 

 Regular  Social  Occasional  Rare  Never 

 Yes  No 
 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?)