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Donald S. Marks, M.D., P.C.

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General Patient Information Form

Please fill in as completely as you can

• Patient Name
• Highest Education
• Tobacco Usage Never
  Unknown if ever
  Former
  Current some days
  Current every day
• If you selected an option in Tobacco Usage that was NOT "never" or "unkown if ever", please fill out dates under this format: Year started: Year stopped (leave blank if irrelevant): Average PPD:
• Diet (select all that apply):
• Well balanced
• Poorly balanced
• Diabetic
• Vegetarian
• Lactose Intolerant
• Other
• If selected "other" for diet, please specify:
• Current height (in ft. and inches)
• History of abuse (select all that apply):
• Physical
• Sexual
• Emotional
• Ages if abuse occurred:
• Have you had any of the following testing?
• CT brain scan
• CT neck scan
• CT back scan
• Other CT scan
• MRI brain scan
• MRI neck scan
• MRI back scan
• Other MRI scan
• EEG(brain wave test)
• EKG(heart)
• Carotid Ultrasound
• EMG/NCV
• Previous neurologist

• Where Raised (Town/city)
• Military Service
• Childhood developmental problems? (If none, write "None")
• Alcohol Usage Never
  Rare ( < 1/Month)
  Occasional (1x/mo to 3x/week)
  Daily
• Past substance abuse history (what and when):
• Current other substances:
• Driving (select all that apply):
• I am driving
• I am NOT driving
• Accidents (within last 2 years)
• No accidents (within last 2 years)
• Citations (within last 2 years)
• No citations (withint last 2 years)
• Family concerns with driving
• NO family concerns with driving
• Caffeine consumption (coffee, tea, or soda) in cups/day:
• Current weight:
• Hospitalizations for the past 2 years (why, when, where):
• Previous surgeries (what, when, where):
• If you checked any of the testing boxes, please specifiy when and where you got your testing. For "previous neurologist" please specifiy who and where

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Donald S. Marks, M.D., P.C. -- 45 Resnik Road, Suite 205 -- Plymouth, MA, 02360

Tel: (508) 746-5060   Fax: (508) 746-8060