Neurology Follow Up Form

Thank you for choosing Vista Healthcare, attached is the Neurology Follow Up Form. Please be aware this will take roughly 5-10 minutes to complete and you must click save to complete your submission, failure to do so will result in a loss of the information you have entered. Thank you!
Patient Information
Patient Name*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
ID*
Date of Birth*
Date*
Email Address: (this will be used to send you a copy of this paperwork after completed. No further emails will be sent)*
example@example.com
Please explain in detail the reason of your visit today, related to your NEUROLOGICAL problem:*
Have you had any new or worsening medical problems since your last clinic visit?*

YesNo
If yes, please describe:
Please list your new medications and new allergies since last visit:*
Have you had any emergency department visits or hospitalizations since your last clinic visit?*

YesNo
If yes, why?
Are you currently in treatment for a mental health condition?*

YesNo
If yes, with whom?
Have you received any previous diagnostic tests since your last visit?*

NoneMRICT ScanEMGLab WorkVideo EEGEEGLP-lumbar punctureNeuropsychologial TestingHolter Monitoring
Please specify Date and Body Region of tests performed:
Please specify facility where the test was performed:

IHCRevere HealthOther
Have you had any consultations since your last visit?*

YesNo
If yes, with whom? Please select all that apply.*

Primary CareBehavioral HealthCardiologyEndocrinologyNephrologyNeurosurgeryOncologyOrthopedistPulmonologyRheumatologySleep MedicineSpine SurgeryOther Medical or Surgical Specialist
Please specify "Other Medical or Surgical Specialist" if applicable:
Have you had any physical therapy or chiropractic care since your last clinic visit?*

YesNo
If Yes, how many sessions:
Results from physical therapy or chiropractic care:
What activities are impaired during the day?:*

NoneBendingBowel and Bladder ManagementChoresDressing and UndressingDrivingExerciseFunctional TransfersIntimacyLiftingPersonal Hygiene and GroomingRange of MotionRecreation-HobbiesSelf feedingSittingSleepingStandingTwistingWalkingWorkOther

Patient Information