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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
Calendar
Allergies / Contraindictations
Have you ever had an allergic reaction to any medication?  If yes, please list medication and reaction: *This question is required.
  • * This question is required.
Are you currently taking any medication? *This question is required.
Medications
Please list any medications (presciption and over the counter) you are currently taking (including vitamins and aspirin):
Preferred Laboratory: *This question is required.
  • * This question is required.