Comprehensive Neurology Specialists | Forms

COMPREHENSIVE NEUROLOGY SPECIALISTS

Welcome to Comprehensive Neurology Specialists

Patient Portal

Medical Questionnaire

First Name Required*

Last Name Required*

Email Required*

Date Of Birth Required*

Other Medical History Required*

Social History Required*

Tobacco Use

Non Smoker

Smoker

Former Smoker

Quite Date

How Often Do You Smoke

Daily

Some days, but not every day

#Of Cigarettes some in a day

Alcohol Use Required*

How often did you have a drink containing alcohol in the past year?

Never

Monthly or less

2 to 4 times a month

2 to 3 times per week

4 or more times a week

How many drinks did you have on a typical day when you were drinking in the past year?

1 or 2 3 or 4

5 or 6

7 to 9

10 or more

How often did you have six or more drinks on one occasion in the past year?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Family History Required*

Check if any first degree relative has any Medical Problem

Medical Conditions	Father	Mother	Siblings
High Blood Pressure	Yes No	Yes No	Yes No


High Cholesterol	Yes No	Yes No	Yes No


Heart Disease	Yes No	Yes No	Yes No


Diabetes	Yes No	Yes No	Yes No


Stroke	Yes No	Yes No	Yes No


Cancer	Yes No	Yes No	Yes No


Migraines	Yes No	Yes No	Yes No


Thyroid Issues	Yes No	Yes No	Yes No


Alcoholism	Yes No	Yes No	Yes No


Mental Illness	Yes No	Yes No	Yes No


Others/Specify	Yes No	Yes No	Yes No

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Hours of Operation

Mon	:	08:00 AM to 03:30 PM
Tue	:	08:00 AM to 03:30 PM
Wed	:	08:00 AM to 03:30 PM
Thu	:	08:00 AM to 03:30 PM
Fri	:	08:00 AM to 11:30 AM