Blue Sky Neurology (T) 303.781.4485 (F) 720.274.0064 ( W) www.BlueSkyNeurology.com

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New Patient History

Name: Date of Birth: Current Age: Today's Date:

Referring Physician: Primary Care Provider:

Reason for Today's Appointment:

Past Medical History: Stroke or TIA Diabetes High blood pressure High cholesterol Heart disease Peripheral vascular disease Seizures

Concussion Migraine Anxiety Depression Hypothyroidism Lung disease Sleep apnea: Do you use CPAP?

No / Yes

History of cancer: Kidney disease Bleeding disorder Reflux Ulcers Arthritis Cataracts

For Women: Are you pregnant? N / Y

Other Conditions:

Prior Surgeries and Dates:

Medication Allergies:

Medications: (Include all prescriptions and over-the-counter medications, including vitamins, supplements, and herbs)

Name Dosage Frequency ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________

___________________________________________________________________

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Blue Sky Neurology (T) 303.781.4485 (F) 720.274.0064 ( W) www.BlueSkyNeurology.com

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New Patient History (Continued)

Patient Name: ____________________________

Symptoms:___ Recent weight loss; ___ lbs___ Recent weight gain; ___ lbs___ Fever___ Night sweats___ Fatigue___ Blurred Vision___ Double vision___ Blindness___ Hearing loss___ Ringing in ears___ Chest pain___ Palpitations___ Shortness of breath

Is today’s visit related to an injury? No / Yes - Date: __________________________________________

Family History:Father: Alive / Deceased, Medical Conditions: _____________________________________________Mother: Alive / Deceased, Medical Conditions: _____________________________________________Siblings: # of Brothers _____ # of Sisters _____ Medical Conditions: ____________________________Number of Children: _____ Medical Conditions: ____________________________________________Does anyone in your family have symptoms similar to yours? _________________________________Are any medical conditions prominent in your family?

Social History:Birth Place: _______________ Education: ___________________ Occupation: ____________________Marital Status: ____________ Who lives with you? ____________________________________________Number of caffeinated beverages per day (e.g. coffee, soda, tea): __________________________Smoking: No / Yes - Packs per day: _____ Number of years smoked: _____ Quit date: ____________Alcohol: No / Yes - Amount per week: __________ Have you recently tried to cut down? __________Marijuana: No / Yes - Frequency: ______________ Other Drugs: No / Yes - Which: ________________

___ Swelling of feet or ankles___ Fainting___ Frequent cough___ Difficulty breathing___ Coughing up blood___ Productive Cough___ Nausea___ Frequent indigestion___ Black, tarry or bloody stools___ Difficulty urinating___ Incontinence___ Burning with urination

___ Excessive thirst___ Unusual appetite___ Frequent urination___ Rashes___ Recent change in wart/mole___ Easy bleeding or bruising___ Depression ___ Anxiety___ Difficulty falling asleep___ Early morning awakenings___ Feeling persistently sad or blue___ Loss of ability to enjoy life