Abnormal - Neurologist Upland, CA | Dr. Jeffrey Ries D.O.

1 Cardiovascular Abnormal Electrocardiogram Aortic Stenosis Atrial fibrillation Cardiac arrest Chest pain Congestive heart failure Heart valve replacement Hypertension Murmur Heart attack Palpitations Peripheral vascular disease Pulmonary embolism Faint Ventricular septal defect Respiratory Asthma Bronchitis, chronic Cough Emphysema Lung Cancer Pneumonia Shortness of breath Sinusitis, chronic Digestive Appendicitis Blood in stool Colon cancer Constipation Diarrhea Diverticula of intestine Esophageal reflux Heartburn Hemorrhoids Hepatitis Hernia Incontinence of feces Intestinal obstruction Irritable bowel syndrome Liver disorder Nausea Nausea with vomiting Peptic ulcer Rectal bleeding Vomiting Endocrine/Metabolic/Immune Type I Diabetes insulin use Type II Diabetes non insulin High cholesterol High thyroid Low thyroid Pituitary gland disorder Vitamin deficiency Weight gain.

2 Abnormal Weight loss Neurologic Alzheimer s disease Convulsions CVA cerebrovascular accident Gait abnormality Headache Hemipelgia Lack of coordination Meningitis Migraine Multiple Sclerosis Neuropathy Numbness Parkinson s Disease Post stroke paralysis Speech disturbance Renal/GU Bladder disorder Kidney stone Painful urination ESRD End stage renal disease Family history of Prostate cancer Blood in urine Impotence cause undetermined Prostate cancer Prostatic hypertrophy benign Urinary incontinence Hematologic Anemia Leukemia Transfusion reaction Musculoskeletal Arthritis rheumatoid Backache Bone infection Bunion Bursitis Connective tissue disease Ganglion Joint pain Muscle spasm Osteoporosis Rotator cuff syndrome of shoulder Sciatica Breast Abnormal mammogram Breast mass Nipple discharge Skin Basal cell carcinoma Cellulitis and abscess Contact dermatitis Edema Malignant melanoma Skin disorder Psychiatry Alcohol withdrawal Anxiety disorder Bipolar disorder Insomnia Major depression recurrent Major depression single episode Mental retardation Panic disorder Schizophrenia Gynecologic Abnormal PAP smear Cervical cancer Hormone replacement therapy Menopausal syndrome Pelvic pain Polycystic ovaries Obstetric Diabetes gestational Infertility Spontaneous abortion Tubal pregnancy Injury/Poisoning Concussion Fracture Head injury Head injury, closed Motor Vehicle Accident Nerve injury Never Current Former Tobacco Alcohol Illegal Drugs Patient Medical HistoryName:_____ Have you ever had a blood transfusion?

3 Yes No If yes approx. dates: _____ Cardiovascular Abdominal aneurysm _____ CVA _____ Family history non contributory _____ Heart disease _____ Hyperlipidemia _____ Hypertension _____ Sudden death _____ Syncope faint _____ Transient Ischemic Attack TIA _____ Endocrine Diabetes Type I _____ Diabetes Type II _____ Hyperthyroidism _____ Hypothyroidism _____ Morbid obesity _____ Neurologic Alzheimer s disease _____ Chorea _____ Common migraine _____ Convulsions _____ Gait abnormality _____ Hearing loss _____ Huntington s disease _____ Involuntary movement disorder _____ Meningitis _____ Motor neuron disease _____ Multiple Sclerosis _____ Neuropathy _____ Parkinson s disease _____ Spinal cord disease _____ Stroke _____ TIA _____ Respiratory Asthma _____ Chronic bronchitis _____ Emphysema _____ Lung disease

4 _____ Lung cancer _____ Sleep apnea _____ Hematologic Anemia _____ Psychiatric Anxiety disorder _____ Bipolar disorder _____ Dementia conditions _____ Depression _____ Psychiatric disorder _____ Gastrointestinal Anus cancer _____ Colon cancer _____ Intestinal obstruction _____ Liver disorder _____ Breast Breast cancer _____ Breast cyst _____ Cancer Cancer _____ Musculoskeletal Arthritis, rheumatoid _____ Joint disorder _____ Muscle disorder _____ Muscular dystrophy _____ Family Medical HistoryPlease check all that apply. Use the line provided to add details of the family member and his/her current health. Please include maternal or paternal where appropriate. Hospitalizations/Surgeries Year Hospital Reason for your Hospitalization/Surgery _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Jeffrey D.

5 RIES, 1310 SAN BERNARDINO ROAD, # 101 upland , CA 91786 (909) 579-0779 210 FWY 10 FWY 60 FWY FOOTHILL BLVD E. ARROW HWY SAN ANTONIO HOSPITAL NIMPORTANT INFORMATION PLEASE READ **Our suite is located through the glass door on the left end of the building (Note: bathrooms are located in the hall of the main building. There is no bathroom located in the office.) **Please bring a list of your current medications to your appointment **Please bring the films or CDs from any recent studies to your appointment. (If your studies were done at San Antonio Hospital, disregard this) **ALL PATIENTS ARE SUBJECT TO A 24 HOUR CANCELLATION FEE! SEE FINANCIAL POLICY FORM FOR MORE DETAILS. **Para nuestros pacientes que hablan solamente espa ol, les agradeceriamos si pudieran traer un intreprete que hable ingles.