Name______History, 1
New Patient Health History Today’s Date: ___/___/______
NAME______Date of Birth ____/____/______
Address______
Current Phone Number(s) W______H______C______
Single Married Divorced Widowed Partnered // Live Alone__ With Others__
If you have children, please list their ages: ______
Name______History, 1
MEDICATIONS, VITAMINS, NUTRITIONAL SUPPLEMENTS
List name, dose, and number taken each day
Name______History, 1
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Name______History, 1
MEDICATION ALLERGIES or SENSITIVITIES (please describe briefly what happens)
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OTHER ALLERGIES
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PAST MEDICAL PROBLEMS/SURGERY/HOSPITALIZATIONS
Name______History, 1
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Name______History, 1
Have you had : Chicken Pox Y/N Mumps Y/N Measles Y/N German Measles Y/N
Hepatitis Y/N (if yes, what kind?____) Tuberculosis Y/N
When was your last: tetanus booster ____ flu shot____ pneumovax (pneumonia shot)_____
Have you had immunizations against (when): Measles/mumps/rubella ____ Hepatitis A___
Hepatitis B____ Polio____
Name______History, 1
FAMILY HISTORY:
Name______History, 1
Problem Which Relative(s) At What Age(s)?
Depression______
Alchoholism______
Other Psychiatric______
Melanoma______
Colon Cancer______
Breast Cancer______
Ovarian Cancer______
Prostate Cancer______
Heart Attack/Coronary Artery Disease______
Diabetes______
Osteoporosis______
Dementia/Alzheimer’s______Other______
Name______History, 1
Name______History, 1
OTHER HISTORY
Name______History, 1
Ever smoked? No Yes
If Yes: How many packs/day______
How many years?______
When did you quit?______
Smoking Currently? No Yes
If Yes: How much?______
Do you drink Alcohol? No Yes
If Yes: How many drinks/day (average)___
If Yes:
Do you ever think you should cut down? Y N
Do you ever feel guilty about drinking? Y N
Do you get annoyed if others criticize
your drinking? Y N
Do you ever drink an “eyeopener”? Y N
Name______History, 1
-Have you had sex in the last 3 months? Yes No
-How many sexual partners have you had in the last 5 years? ______
-Your sexual partner(s) are/have been men____ women____ both_____?
-Do you use contraception? Yes / No If Yes, what?______
-Have you ever had a sexually transmitted disease? Yes /No If Yes, what?______
-Do you use protection against sexually transmitted disease? Yes/ No If Yes, what?______
-Have you ever used “recreational drugs”? yes/ no If Yes, have you used needles? Yes / No
-Have you ever had a blood transfusion? Yes/ No When?______
-Do you exercise regularly? Yes / No If Yes, What and How often?______
-Do you drink 4 8-oz glasses of milk, or the equivalent, daily? Yes / No
Do you take calcium? Yes/ No
-When did you last see a dentist? ______eye doctor?______
-Please list the name and specialty of any other health care professionals you see:
Name______History, 1
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Name______History, 1
Name______History, 1
Have you completed a Living Will or other Advance Directive? Yes / No
If you were unable for some reason to make medical decisions for yourself, who would you want to make those decisions for you? (for example, if you were unconscious after a bad auto accident, or had had a major stroke)
Not Sure______
(1) Name:______Relationship to you______
Address ______
Phone number ______
Comments______
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Is this person aware that s/he would be responsible for decision making under such circumstances? Y/ N
PLEASE CHECK ANY OF THE FOLLOWING THAT APPLY TO YOU
Name______History, 1
Hayfever__ Decreased Hearing__ Nose Bleeds__ Nasal Congestion__ Snoring__ glaucoma__
Hypothyroid__ Hyperthyroid__ Goiter__
New weight gain___ New weight loss___
Unusual fatigue____ Diabetes___
Cough__ Wheezing__ Asthma__
Shortness of Breath__ Past Pneumonia__
Positive TB Skin Test__ Sleep Apnea__
Chest Pains__ Angina__ Palpitations__
Irregular Heart Beat__
New Fatigue or Shortness of Breath with Exercise__ Fainting__ Lightheadedness__
Leg Swelling__
Heartburn__ Abdominal Pain__
Swallowing difficulty__ Nausea__
Vomiting__ Constipation__ Diarrhea__
Black BM ___ Rectal Bleeding ___
Irritable Bowel__ Inflammatory Bowel Disease__
Gall Bladder Problems__ Ulcers__
Stomach bleeding__ Hepatitis__ Hernia__
Burning or Pain with urination__
Night time urination__
Difficulty urinating__ Incontinence__
Increased Frequency of urination___
Bladder infections__
Kidney stones__ Kidney Infections__
Blood in the Urine__
Joint pain__ Hot/Swollen Joints__ Joint Injury__
Gout__ Osteoarthritis__ Fractured Bones__
Muscle pain__ Osteoporosis__
Clinician’s Notes
Lyme Disease__ Back Pain__ sciatica__
Skin Cancers__ Eczema__ Hives__ Acne__
Cold Sores__ Genital Herpes__ Psoriasis__
Headaches__ Numbness or Tingling__
Weakness or paralysis__
History of stroke__ Vision changes__
History of meningitis__ Tremor__
Difficulty walking___ Balance problems___
Unusual Bruising/bleeding__ Blood Clots __ Phlebitis__ Anemia__ Swollen Glands___
Sad Mood__ Difficulty Sleeping__ Anxiousness__ Suicidal Thoughts__ Inability to enjoy activities__
History of Abuse__
History of treatment for emotional problems____
Sexual function concerns___
Clinician’s Notes:
Name______History, 1
MEN ONLY
Prostatitis__ Discharge from Penis__ Problems with erections__ Pain or lump in testicles/scrotum___
Name______History, 1
WOMEN ONLY
Name______History, 1
Periods started at (what age)_____
Pregnancies Y/N (How many)____
Live Births Y/N (How many)_____
Abnormal Pap smears? Y/N
If yes, when was the last one?______
Vaginal spotting __
Abnormal vaginal discharge__
Do you still get a period? Y/N
If No, at what age did your periods end? ____
Have you had a hysterectomy? Y/N
If yes, were your ovaries also removed? Y/N
If you no longer get periods, skip the following questions.
Last Menstrual Period (when)_____
Bleeding between periods ___ Heavy periods ___ Painful periods____
Name______History, 1
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Please list any other symptoms or concerns that you want to make us aware of at this visit
(if we cannot address them all today, we will arrange to see you again very soon)
Name______History, 1
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