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.
Please download,complete and print this form Health History Form_Adults_Dr Green_updated Jan 2024
Or complete the online form
Adult Health History FormKristin 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 OVERTHE 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.
CANCER PATIENTS, ONLY
FOR ALL OTHER CONDITIONS
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…
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
NOSE AND SINUSES
MOUTH AND THROAT
MALE REPRODUCTIVE SYSTEM
FEMALE REPRODUCTIVE SYSTEM
MENTAL / EMOTIONAL / PSYCHOLOGICAL
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