South Florida Neurology Associates

Patient Medical History

Are you

Please check if you have had any of the following
Do you have a Pacemaker?    

Do you have a Defibrillator?

Please check any conditions that you have now or have had in the past

Do you smoke?

Do you drink alcohol

Do you use marijuana, cocaine and/or any unprescribed drugs


I have answered the questions truthfully and to the best of my knowledge, without intent to falsify information. I understand that incorrect information I may have provided could affect recommended treatment and ultimately affect the course and outcome of my medical condition.

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