Is the patient q left- or q right-handed? Which side of the body have the movement symptoms mainly affected? ___________________________ What medications has the patient taken to manage the symptoms since the neurological diagnosis? ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________
What kind of professional work did / does the patient do? _________________________________________
Does the patient have a history of brain injury or possible brain injury? q Yes q No For example, a history of trauma or repeated concussions related to combat, work activities, or sports. Please provide details here: _____________________________________________________________________ ________________________________________________________________________________________________
Is there a family history of movement or memory disorders or other neurological diseases? q Yes q No Please list diagnoses and the relationship of the person to the patient( e. g., Alzheimer’ s disease – father) _________________________________________________________________________________________________ _________________________________________________________________________________________________
Most recent physician who managed the patient’ s neurological diagnosis and care: Name of physician: _______________________________________________________________________________ Specialty( neurology, primary care, etc.): ______________________________________________________________ Facility / Hospital: ________________________________________________________________________________ Facility address: __________________________________________________________________________________________ City: ____________________________________________ State / Province: _______ ZIP code: ______________ Phone: ___________________________________________ Fax: ___________________________________________ Email( if available): ________________________________________________________________________________
11
If patient is under care of hospice: Name of hospice agency: __________________________________________________________________________ Facility address( if person is residing in inpatient hospice): ___________________________________________________________ __________________________________________________________________________________________________ Contact person: __________________________________________________________________________________ Phone: ________________________________________ Email: __________________________________________
If patient resides in a skilled nursing or assisted living facility: Name of facility: __________________________________________________________________________________ Facility address: __________________________________________________________________________________________ Contact person: __________________________________________________________________________________ Phone: ________________________________________ Email: __________________________________________