Neurology Form

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Phone Number of Doctor *

If former smoker, when did you quit?

Name of your Pharmacy *

Are you on supplemental Oxygen? *

Yes

No

Address *

New Patient Neurology Form

Past Medical History: (check all that you have or had) *

Diabetes

Seizures

Allergic Rhinitis

Obstructive Sleep Apnea

Obesity

Heart Attack/Angina

GERD-Reflux

Chronic Pain Syndrome

Restless Leg Syndrome

Hypertension

COPD

Fibromyalgia

Depression

Stroke

Asthma

Migraines

Narcolepsy

Chronic Fatigue Syndrome

None

Why were you referred to us? *

Are you a previous smoker? *

Yes

No

Allergies: *

How long has problem existed? *

Address of your Pharmacy *

If Yes, Please upload your medication "or" bring it to your appointment

We were unable to upload your file. Please ensure your file is 10MB or smaller in size.

Employment Status *

Full-Time

Part-Time

Self-Employed

Unemployed

Retired

Legally Disabled

Student

Marital Status *

Single

Married

Divorced

Widowed

Separated

Caffeine use: *

Previous Hospitalizations: *

Cell Phone *

Are you a current smoker? *

Yes

No

Phone *

Phone Number of Doctor *

Have you ever been addicted to drugs/alcohol? *

Yes

No

Thank you for contacting us! If needed, you will hear back within 48-72 hours.

Marital Status *

Single

Married

Divorced

Widowed

Separated

Do you take any medications? *

Yes

No

Alcohol use: *

Phone of your Pharmacy *

Address

Email: *

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Surgical History: *

Referring Doctor's Name/Facility *

Date of Birth *

Name: *

Social Security Number

Do you exercise on a regular basis? *

Yes

No

Family History: (Check all that apply) *

Insomnia

Snoring

ADHD

Narcolepsy

OSA

RLS

Hypertension

Kidney Disease

Fibromyalgia

Diabetes

Obesity

Cancer

Stroke

Asthma

GERD

Seizures

Heart Disease

COPD

None

Primary Care Doctor's Name/Facility *

Emergency Contact *

Race *

American Indian/Alaska Native

Asian

Native Hawaiian/Other Pacific Islander

Black/African American

White

Hispanic

Other Race

Other Pacific Islander

Unreported/Refused to Report

***Please scroll to the top to submit your form***

Emergency Contact Phone Number *

Ethnicity *

Hispanic/Latino

Not Hispanic/Latino

Unreported/Refused to Report

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