Medical Questionnaire — Raul Mandler, MD: Board-Certified in Neurology

First Name

Middle Name

Last Name

Gender

Date of Birth

Age

Reason for ailment for which you were referred to a neurologist? (Please explain what you felt was not right and when in as much detail as possible)

Past Medical History

Is your father still alive? If so, how old? If not, at what age did they die?

Is your mother still alive? If so, how old? If not, at what age did they die?

Are your grandparents still alive? If so, how old? If not, at what age did they die?

Do you have aunts or uncles? If so, what are their sexes, age, and health status?

Do you have siblings? If so, what are their sexes, age, and health status?

Do you have children? If so, what are their sexes, age, and health status?

Tell us more about yourself. How far did you go in school?

What is your occupational history, and at what age did you start working those jobs?

Do you smoke? If yes, how much?

Do you drink alcohol? If yes, how many drinks per day?

Have you used recreational drugs? If yes, which ones and how much?

Who lives in your household?

Do you take any medications? What is the daily amount? Date of first dose taken and last?

Did you have any childhood diseases? If so, at what age?