Health History Forms PDF Print E-mail

Please print and complete the appropriate Health History Forms required by your doctor, and bring the completed paperwork with you to your appointment.

Adult Neurology

Ingrid Abols, M.D.

Rajiv Aggarwal, M.D.

Janiece Aldinger, M.D.

Irfan M. Altafullah, M.D.

Elias Bazakos, M.D.

Sarah M. Benish, M.D.

Ivan L. Brodsky, M.D.

Xiaoming Dong, M.D., M.Sc.

Gail Francis, M.D.

Masood R. Ghazali, M.D.

Jessica O. Heiring, M.D.

Charles H. Horowitz, M.D.

Jack E. Hubbard, Ph.D., M.D.

Bruce I. Idelkope, M.D.

Allan P. Ingenito, M.D

Moeen A. Masood, M.D.

Sotirios A. Parashos, M.D., Ph.D.

Daniel C. Randa, M.D.

Joanne B. Rogin, M.D.

Leland J.C. Scott, M.D., Ph.D.

Steven D. Stein, M.D.

John E. Trusheim, M.D.

Yelena V. Usmanova, M.D., M.Sc.

Alexander Y. Zubkov, M.D., Ph.D.

Felix Zwiebel, M.D.

Pediatric Neurology

Donald J. Chadwick, M.D.

 - Pediatric Neurology Information – health history form for all patients

 - Headache Information and History

 - Seizure Information and History

Armantina M. Espinosa, M.D.

Allan P. Ingenito, M.D.

Rehabilitation Services

Rehabilitation

Neurodiagnostic Testing Forms

MRI Medical History Questionairre

 
Clinic Locations

GOLDEN VALLEY / MAIN OFFICE
4225 Golden Valley Road, Golden Valley, MN 55422
(763) 588-0661

BURNSVILLE
Oak Ridge East Professional Building
675 E. Nicollet Boulevard, Suite 100, Burnsville, MN 55337
(952) 435-8516 (Neurology services)
(952) 898-5000 (Rehab services)

COON RAPIDS
3833 Coon Rapids Blvd., Suite 100, Coon Rapids, MN 55433
(763) 427-8320

EDINA
Southdale Place
3400 West 66th St, Suite 150, Edina, MN 55435
(952) 920-7200 (Neurology services)
(952) 920-8088 (Rehab services)

MAPLE GROVE
North Memorial Medical Office
9825 Hospital Drive, Suite 103, Maple Grove, MN 55369
(763) 302-4114

OUTREACH LOCATIONS
Twin Cities Metro, Greater Minnesota & Western Wisconsin