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MUNTHER S.

TABET, MD
Patient portal:https://10577.portal.athenahealth.com

http://tabet-neurology.weebly.com
Facebook: Munter S. Tabet, MD PA
MEDICAL HISTORY QUESTIONAIRE:
Patient Name: __________________________________

DOB:_______________

***Please review each section and circle all that apply***

Allergies:
Penicillin

Sulfa

Aspirin

Ibuprofen

NSAIDS

Other:___________________________________________________________________________________________
__

FAMILY MEDICAL HISTORY:


Father:
Aneurysm

Autoimmune disease

Brain Tumors

Cancer

Dementia

Developmental Problems

Diabetes

Epilepsy/Seizures

Headaches/Migraines

Heart Attack (MI)

Heart Disease

High Cholesterol

High Blood pressure


Sclerosis

Parkinson's Disease

Thyroid disorder

Lupus

Multiple

Stroke

Mother:
Aneurysm

Autoimmune disease

Brain Tumors

Cancer

Dementia

Developmental Problems

Diabetes

Epilepsy/Seizures

Headaches/Migraines

Heart Attack (MI)

Heart Disease

High Cholesterol

High Blood pressure


Sclerosis

Parkinson's Disease

Thyroid disorder

Lupus

Multiple

Stroke

Other:___________________________________________________________________________________________
_________________________________________________________________________________________________

Surgical History:

Appendix

Back Surgery

Brain Surgery

Breast Surgery

C-Section

Cancer Surgery

Cataract Surgery

Colonoscopy

ENT/Sinus Surgery

Gallbladder

Gastric Bypass

Heart Surgery

Hemorrhoid

Hernia Repair

Hysterectomy

Knee Surgery

Thyroid Surgery

Tonsil

Tubal Ligation

Other:___________________________________________________________________________________________
__________________________________________________________________________________________________
__

Past Medical History:

/ Angina Shortness of breathe


Eye
disorder / Glaucoma Diabetes
Atrial fibrillation Heart disease / Murmur
Aneurysm
Anxiety
Disorder
Arthritis
Asthma

Autoimmune disease

Back Problems

Bleeding Disorder

Brain Tumors

Cancer

Cerebral Palsy

COPD

Dementia

Depression

Developmental Problems

Diabetes

Epilepsy/Seizures

Fibromyalgia

GERD(acid reflux)

Head Trauma/Injury

Headaches/Migraines

Heart Attack (MI)

Heart Disease

Hepatitis

High Cholesterol

High Blood pressure

Liver Disease

Lung Disease

Lupus

Multiple Sclerosis

Sleep Apnea

Osteoporosis

Parkinson's Disease

Stroke

Thyroid disorder

Kidney Disease

Vertigo

Other:___________________________________________________________________________________________
__________________________________________________________________________________________________
__

Preventative and Screening:


Flu shot:__________________
vaccine:____________________

Pneumonia:________________

Colonoscopy:_______________ Mammogram:________________
smear:________________________

Shingles
Pap

Social History:
Right handed / Left handed / Ambidextrous
Do you smoke: Yes / No / Never
When did you quit:_________________________________
If so, how many cigarettes/cigars per day: _____________
Age you started smoking: _____ ___
Do you chew tobacco/snuff? Yes / No
Do you drink Alcohol: Yes / No / Never
Have you ever drink in excess in the past:
Yes / No / Never
How long ago did you quit:________________
On average how many days a week do you have more than 4 drinks: ________
Do you use any illicit drugs: Yes / No / Never / Past
When did you
quit:________________________________
What drugs: _______________________________________ How often:________________________________
Do you live: Alone / With others
What type of job do you
do:______________________________________

Do you have one of the following: Will / DNR /


Other:_________________________________________________

Do you have any problems with any of the following:


Blind or serious difficulty seeing
Difficulty concentrating, remembering or making decisions
Difficulty dressing or bathing
Hard of hearing or deaf in one or both ears

Deaf or serious difficulty hearing


Difficulty doing errands alone
Difficulty walking or climbing stairs

______________________________________________
Patient Signature

______________________
Date