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. 

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Adult Health History Form
Kristin Stiles Green, NMD


SUCCESSFUL HEALTH CARE IS ONLY POSSIBLE WHEN THE PROVIDER HAS A COMPLETE UNDERSTANDING OF THE PERSON PHYSICALLY, MENTALLY AND EMOTIONALLY.
PLEASE COMPLETE THIS QUESTIONNAIRE AS THOROUGHLY AS POSSIBLE.
PLEASE, FILL AND MARK ANYTHING YOU DON'T UNDERSTAND WITH A QUESTION MARK.

Are you hypersensitive or allergic to:

Current Medications/Supplements/Herbs/Homeopathics:
Please list ALL vitamins, herbs, supplements AND prescription medications OR over the counter medications you are taking, regularly.
Please include ingredients, milligram amounts, how often taken, etc.
For multi-ingredient products, PLEASE BRING IN THE BOTTLES OR CLEAR PHOTOS OF THE FRONT AND BACK LABELS, so I may see the detail.

CANCER PATIENTS, ONLY

FOR ALL OTHER CONDITIONS

SOCIAL HISTORY

SCREENINGS:

FAMILY HISTORY

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

Typical Food Intake - Examples

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

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We are glad to serve you!