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SAVANNAH NEUROLOGY SPECIALISTS, P.C.

  • (912)

    354-7676 Phone

  • (912)

    354-2181 Fax

MEDICAL HISTORY

NAME

DATE

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

___________________

DATE OF BIRTH

AGE

__________________________________________

______________________

OCCUPATION

___________________________________________

HOW LONG________________

WHY ARE YOU HERE? DESCRIBE SYMPTOMS

_______________________________________

_____________________________________________________________________________________

WHEN DID THE PROBLEM START?

___________________________________________________

G E T T I N G B E T T E R / W O R S E ? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

WHO REFERRED YOU HERE?

_______________________________________________________

HAVE YOU SEEN ANOTHER PHYSICIAN FOR THIS, OR A SIMILAR CONDITION? WHOM? WHEN? ____________________________________________________________________

_____________________________________________________________________________________

PLEASE LIST YOUR PRIMARY CARE PHYSICIAN AND THE NAMES/SPECIALTIES FOR ANY OTHER PHYSICIAN PATIENT HAS SEEN. _____________________________________________________________________________________

_____________________________________________________________________________________

*HAVE YOU DIAGNOSTIC TESTING BEEN DONE FOR THIS CONDITION? WHERE? WHEN? (X-RAYS, MRI, CT SCAN, LABWORK, EMG, EEG)

_____________________________________________________________________________________

_____________________________________________________________________________________

*When available, please be sure to bring any and all pertinent medical records, diagnostic testing reports, lab results, and/or actual films to your appointment. If you choose, you may hand deliver records at time of appointment OR have records faxed or mailed at contact address above.

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