Neurology Intake Form

The Neurology Intake Form is designed specifically for neurological practices, capturing the detailed symptom history and clinical timeline that neurologists require for accurate diagnosis. This comprehensive template collects patient demographics alongside a thorough neurological symptom inventory covering headaches (type, frequency, duration, triggers, aura), dizziness and vertigo, numbness or tingling, weakness, tremor, gait disturbances, memory changes, speech difficulties, and vision changes. The headache section uses structured questions aligned with ICHD-3 criteria to facilitate migraine, tension-type, and cluster headache classification.

Built for general neurology, headache medicine, epilepsy, movement disorders, and neuromuscular clinics, this form includes dedicated sections for seizure history (type, frequency, triggers, post-ictal state), prior neurological testing (MRI, CT, EEG, EMG/NCS, lumbar puncture), previous neurology consultations, and a detailed neurological medication history including anticonvulsants, triptans, preventive medications, and neuromodulation devices. The cognitive screening section captures subjective memory concerns, functional changes, and family history of dementia or neurodegenerative disease.

All fields are HIPAA-compliant and structured to support the neurological examination workflow. The multi-page format walks patients through each symptom domain systematically, reducing the chance of omitting critical details. Patients complete the form before their visit, giving the neurologist time to review the history, identify patterns, and plan the examination and diagnostic workup accordingly.