BAY AREA NEUROSURGERY, P.A.
813 S. Parsons Avenue
Brandon, FL 33511
PATIENT HEALTH HISTORY
Review of Systems: Have you recently had problems with the following? Please check the box & describe
 
Constitutional
Integumentary
 
Fever
Skin - Rash - Dry
Itchy - Scaly
 
Weight Loss intentional unintentional
Eyes
 
Excessive Fatigue
Wear Glasses
 
Loss of Sleep
Glaucoma
 
Neurological
Cataracts: Right Left
 
Headache
Double Vision
 
Fainting Spells "Blacking Out"
Ear, Nose, Throat and Mouth
 
Seizures
Wear Hearing Aids
 
Forgetfulness
Hearing Loss
 
Numbness or Tingling
Ear Infections
 
Inability to Concentrate
Ringing In Ears
 
Double Vision Blurred Vision
Vertigo/Dizziness
 
Imbalance
Nose Bleeds
 
Musculoskeletat
Inability to Smell
 
Arm or Leg Weakness
SInus Problems
 
Back Pain or Neck Pain
Psychiatric
 
Arm or Leg Pain
Anxiety
 
Joint Pain or Swelling
Depression
 
Cardiovascular. Date of last EKG:
Other-explain:
 
Chest Pain or Angina
Endocrine
 
High Blood Pressure
Diabetes
 
Irregular Pulse
Thyroid Disease
 
Heart Murmur
Excessive Thirst or Urination
 
High Cholesterol
Hormone Problems
 
Swelling in the Feet or Hands
Hematologic/Lymphatic
 
Leg Pain While Walking
Anemia
 
Respiratory. Date of last chest x-ray
Hemophilia
 
Asthma
Bleeding Tendencies
 
Cough
Hepatitis C
 
Emphysema
Blood Transfusions
 
Shortness of Breath
Allergic/Immunologic
 
Gastrointestinal
Food Allergies
 
Nausea or Vomiting
Inhalant (nasal) Allergies
 
Liver Disease Jaundice
Immunologic Disorders
 
Abdominal Pain
Women only. date LMP:
 
Genitourinary
Are you pregnant?
 
Urinary Tract Infections
Breast Lump
 
Painful Urination
Endometriosis
 
Blood in Your Urine
Cardiologist:
 
Difficulty Starting or Stopping
Oncologist:
 
Incontinence
Pain Management Dr:
 
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