Neuron Medical Corporation is the neurology practice of Liliana Cohen, M.D., Paul Dudley, M.D. and naturopathic medical doctor Kristin Stiles Green, N.M.D. of Thousand Oaks, California. 

CONTACTS

Please download,complete and print this form Health History Form_Adults_Dr Green_updated Jan 2024 

Or complete the online form

Adult Health History Form
Kristin Stiles Green, NMD, FABNO

* required field 

PROACTIVE HEALTH CARE IS ONLY POSSIBLE WHEN THE PROVIDER HAS A COMPLETE UNDERSTANDING OF THE PERSON MENTALLY, PHYSICALLY, AND EMOTIONALLY.
PLEASE COMPLETE THIS QUESTIONNAIRE AS THOROUGHLY AS POSSIBLE.


PLEASE, PRINT!
MARK ANYTHING YOU DON’T UNDERSTAND WITH A QUESTION MARK.

Are you hypersensitive or allergic to:

PLEASE LIST ALL VITAMINS, HERBS, SUPPLEMENTS, PRESCRIPTION MEDICATIONS, AND OVER
THE COUNTER MEDICATIONS YOU ARE TAKING ON A REGULAR BASIS.
Please include ingredients, milligram amounts, how often taken, etc.
PLEASE BRING IN THE BOTTLES OR LABELS or EMAIL US clear photos of the front and back labels of EACH bottle so I can see the details.

GENERAL

CANCER PATIENTS, ONLY

FOR ALL OTHER CONDITIONS

SOCIAL HISTORY

SCREENINGS:

FAMILY HISTORY

Please note if any of these diseases/problems are (or were) applicable to your parents, grandparents, uncles,
aunts, or siblings.
Please note for whom it was a problem.

Typical Food Intake- Examples, as we know it varies…

EXERCISE

For the following sections, please use this KEY:

Y = a condition you have now  N = a condition you have never had   P = had in the past

HEAD

EYES

EARS

NOSE AND SINUSES

MOUTH AND THROAT

SEASONAL ALLERGIES

RESPIRATORY

CARDIOVASCULAR

BLOOD/PERIPHERAL VASCULAR

GASTROINTESTINAL

BONES/BACK/NECK/JOINTS/MUSCLES

NEUROLOGY

SKIN

ENDOCRINE

IMMUNE

URINARY/KIDNEY

MALE REPRODUCTIVE SYSTEM

FEMALE REPRODUCTIVE SYSTEM

MENTAL / EMOTIONAL / PSYCHOLOGICAL

FINANCES

VIOLENCE

Welcome!
We are glad to serve you!