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Neurology Center of Las Vegas
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MEDICATION AND HISTORY
New Patient
ROS
ROS
Name
*
DOB:
*
Symptom Review: Please check all that apply
Headache
Dizziness
Seizure
Loss of Consciousness
Neck Pain
Back Pain
Muscle Aches and Pain
Tremor
History of Stroke
Numbness
Tingling
Muscle Pain
Depression
Anxiety
Balance Problems
Falls Difficulty in Walking
Weakness
Present
Other (please describe)
*
* Required field
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