UCLA Department of Neurosurgery

New Patient Questionnaire

For your first consultation with your neurosurgeon, it is helpful for your physician to review the full details of your medical and social history prior to your visit. Please be prepared with the following information in order to complete the new patient questionnaire:

List of medications (prescription and over the counter, including vitamins and aspirin), including dosage and frequency
Preferred pharmacy address, phone and fax number
Referring physician/primary care physician/and any physician you would like copied to your medical records, address, phone and fax number
List of previous operations/hospitalizations, including type of operation and year
Information on any family history of medical problems

First Name

Last Name

Date of Birth

UCLA Medical Record Number (MRN)

Chief Complaint
Reason for today's visit

Allergies / Conraindictions

Have you ever had an allergic reaction to any medication? If yes, please list medication and reaction:

No
Yes

Survey Completion
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