Skip to content
805.220.4300
1919 State Street, Suite 203, Santa Barbara, CA 93101
South Coast Neurology
Home
Meet the doctors
Disorders
APPOINTMENT
PATIENT INFO
Contact
Home
Meet the doctors
Disorders
APPOINTMENT
PATIENT INFO
Contact
South Coast Neurology
Patient Questionnaire
Name
Date
Age
+-
Specific reason for visit today (max 2)
Date of Last Physical Examination
Date of Last Menstrual Cycle
Current medications (include dosage and direction)
Tobacco usage
Yes
No
If yes, how much?
Employment
Alcohol usage
Yes
No
If yes, # of drinks weekly?
Highest level of education
Medical History: YOU MUST COMPLETE THIS SECTION IF YOU ARE SEEING THE PROVIDER FOR THE FIRST TIME.
*Please check all that applies either to you or your family and give specific details.
Accident
Patient
Family
N/A
Details/Type
Kidney Disease
Patient
Family
N/A
Details/Type
ADHD
Patient
Family
N/A
Details/Type
Learning Disability
Patient
Family
N/A
Details/Type
Arthritis
Patient
Family
N/A
Details/Type
Liver Disease
Patient
Family
N/A
Details/Type
Asthma
Patient
Family
N/A
Details/Type
Lung Disease
Patient
Family
N/A
Details/Type
Blood Disorder
Patient
Family
N/A
Details/Type
Mental Illness
Patient
Family
N/A
Details/Type
Cancer
Patient
Family
N/A
Details/Type
Migraine
Patient
Family
N/A
Details/Type
Dementia
Patient
Family
N/A
Details/Type
Neurological Disease
Patient
Family
N/A
Details/Type
Depression
Patient
Family
N/A
Details/Type
Seizure
Patient
Family
N/A
Details/Type
Diabetes
Patient
Family
N/A
Details/Type
Sinusitis
Patient
Family
N/A
Details/Type
Eye Disorder
Patient
Family
N/A
Details/Type
Skin Disease
Patient
Family
N/A
Details/Type
Glasses/contacts
Patient
Family
N/A
Details/Type
Spine Disease
Patient
Family
N/A
Details/Type
Head Trauma
Patient
Family
N/A
Details/Type
Stomach Disease
Patient
Family
N/A
Details/Type
Hearing Disorder
Patient
Family
N/A
Details/Type
Stroke
Patient
Family
N/A
Details/Type
Heart Disease
Patient
Family
N/A
Details/Type
Thyroid Disease
Patient
Family
N/A
Details/Type
High Cholesterol
Patient
Family
N/A
Details/Type
Surgery
Patient
Family
N/A
Details/Type
Hypertension
Patient
Family
N/A
Details/Type
Other medical/illness history
Patient
Family
N/A
Details/Type
Neurology Visit:
General
Appetite Loss
Chills
Dietary Changes
Fatigue
Fever
Lethargy
Night Sweats
Weight change
gained
loss
N/A
Lbs
Neck
Neck Pain
Neck Stiffness
Swollen Glands
Neurological:
Loss of Consciousness
Numbness
Seizures
Spinning Sensation
Tremor
Visual Changes
Weakness
Tingling
Neurological
Chest Pain
Fainting
Leg Cramps
Palpitations
Rapid Heart Rate
Shortness of Breath
Swelling of Extremities
Skin
Bruising
Excessive Sweating
Hair Loss
Hives
Itching
New Lesions
Rash
Go to Top