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Patient History Checklist

□ Patient’s name
□ Patient’s age
□ Patient’s address
□ Patient’s occupation
□ Patient’s presenting complaint
□ Time of onset of symptoms
□ Previous episode of symptoms
□ Presence of aphasia
□ Presence of ataxia
□ Presence of numbness
□ Presence of loss of motor function
□ Episodes of impaired vision
□ History of abnormal movements and/or tremors
□ Incontinence of urine
□ Presence of dizziness
□ Presence of nausea/vomiting
□ Presence of fatigue
□ Presence of irritability
□ Difficulty concentrating
□ Difficult}' sleeping
□ Presence of chest pain
□ Presence of shortness of breath
□ Risk factors
□ Hypertension
□ Heart disease
□ Diabetes mellitus
□ History of transient ischemic attacks
□ Cigarette smoking
□ History of trauma
□ Medical history
□ Hospital admissions
□ Surgical history
□ Medications, including over-the-counter medications, prescription medications, and illicit drugs
Patient History Checklist

□ Patient’s name
□ Patient’s age
□ Patient’s address
□ Patient’s occupation
□ Patient’s presenting complaint
□ Time of onset of symptoms
□ Previous episode of symptoms
□ Presence of aphasia
□ Presence of ataxia
□ Presence of numbness
□ Presence of loss of motor function
□ Episodes of impaired vision
□ History of abnormal movements and/or tremors
□ Incontinence of urine
□ Presence of dizziness
□ Presence of nausea/vomiting
□ Presence of fatigue
□ Presence of irritability
□ Difficulty concentrating
□ Difficult}' sleeping
□ Presence of chest pain
□ Presence of shortness of breath
□ Risk factors
□ Hypertension
□ Heart disease
□ Diabetes mellitus
□ History of transient ischemic attacks
□ Cigarette smoking
□ History of trauma
□ Medical history
□ Hospital admissions
□ Surgical history
□ Medications, including over-the-counter medications, prescription medications, and illicit drugs

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