Robert D. MacLachlan, MD  Board-Certified Neurologist

Please complete this questionnaire in as much detail as possible. 

Name:            Date: 

Date of Birth:    Age:    Handedness:    Right     Left

Height   Weight

Referring Doctor:  Primary care physician: 

Current Medical History:

Present Problem: What specifically brings you to see the doctor today?  Please describe your symptoms

(i.e. right leg and back pain, etc.):

When did the symptoms begin? (month / year): 

Please list all other doctors and chiropractors that you have seen for this problem and the tests that have been performed.

Date                            Doctor                                                 Tests                           Location

Do you have medication allergies?                            Yes      No

If yes, please list all of your allergies:

Please list all medications / drugs you are currently taking, the dosages and the frequency.  Please include any regular and occasional medications, as well as over the counter medications

Have you been in physical therapy?                           Yes      No

If so, where?  For how long? 

Starting when? Ending when?

Have you had chiropractic treatment?                        Yes      No

Have you used any sort of brace or support?            Yes      No

Do you have a pacemaker?                                        Yes      No

Past Medical History:

Please check any of the following medical problems you have had and explain the problem in the space provided below:

Explanation:

Please list all surgeries, your surgeons and the dates of the surgeries.

Surgery                                                           Surgeon                                                          Date

Please list all hospitalization, your doctors and the dates you were hospitalized.

Reason for hospitalization                              Doctor                                                             Date

How many pregnancies?  How many births? 

Social History:

Where do you live? (City name) 

Are you:           Married            Single              Divorced          Widowed

Are you employed?                 Yes      No

Are you retired?           Yes      No        When was your last day of work? 

Where do (did) you work? 

Do you use tobacco?              Yes      No                    How much per week? 

Do you use alcohol?               Yes      No                    How much per week? 

Do you use illicit drugs?          Yes      No                    How much per week? 

Family History:

Please check any health problems and list member of the family it affected.

  Cancer -  Heart Disease -  

            What kind?Diabetes -

  High blood pressure -  

  Neurological Disease -

        What kind? (seizures, headaches, movement problems, stroke, etc.)

Healthcare Maintenance:

Please complete this section if you are female.

Age at the onset of menstruation:Age at onset of menopause:Date of last period:

When was your last PAP smear? (month/year):Results: 

When was your last breast exam? (month/year):Results: 

Do you know how to perform self-breast examinations?       Yes      No 

Please complete this question if you are a female age 40 or over.

When was your last mammogram? (month/year)Results: 

Please complete this section if you are over age 45.

When was your last complete physical exam?Results: 

When was your last cholesterol screening test?Results:

When was your last blood sugar screening test?Results:

When was your last EKG?Results:

When was your last colon cancer-screening test (i.e. hemocult, sigmoidoscopy, colonoscopy)?

 Result: 

Please complete this question if you are a male age 50 or over.

When was your last prostate cancer screening test (i.e. prostate exam, PSA blood level)?

 Result: 

Have you had a flu or pneumonia shot?          Yes     No  If yes, when? 

Please check YES if you have any of the following: