new patient medical questionnaire

Name SS#

Birthdate Age Height inches Weight lbs. Sex

Address Chart Number

Referring Doctor and Address

Doctor You Are Seeing Today Today’s Date

Do you have a living will? YesNo(circle)Do you have an advanced directive?YesNo(circle)

If you have a living will or an advanced directive, please provide us with a copy for your chart.

PRESENT PROBLEM

  1. Chief complaint: Why are you seeing the doctor today? Please describe your symptoms and length of time you have had them:
  1. Have had this problem before? How long?
  2. Have you had any treatment for this problem?

What kind of treatment?

For how long?

Who treated you?

  1. Were you injured at work?

Date of injury: Did you report it? Date you last worked:

Details of injury:

  1. Are you symptoms accident related? Date of accident:
  2. Is there a law suit in this accident/injury?
  3. Occupation
  4. Have you had physical therapy?
  5. Have you had epidural steroid injections?

PAST HISTORY

  1. Operations: Please list type, date, and Doctor
  2. Hospitalizations (not operations): Please list reason, year, and Doctor
  3. Allergies to medicines:
  4. Medicines you are presently taking and the dosage:
  1. Are you a diabetic?
  2. Do you take Coumadin?

In the event a MRI is needed:Do you have a pacemaker?

Do you have aneurysm clips in your brain?

Are you claustrophobic?

REVIEW OF SYSTEMSIf you answer yes, please elaborate:

HEENT

Frequent headaches

Dizziness

Falling out spells

Ringing in your ears

Trouble hearing

Blurred vision or double vision

Glaucoma

Frequent nosebleeds

Difficulty swallowing

Hoarseness

Change in your voice

CARDIORESPIRATORY

Chest pain

Heart attack

High blood pressure/Hypertension

Shortness of breath Pulmonary embolus Wheezing or asthma

Coughing up blood Chest pain with exertion Arm, neck, or jaw pain with exertion Feel your heart pound, skip or race Have had a heart murmur Ankle swelling Phlebitis

GASTROINTESTINAL

Change in weight or appetite Indigestion Nausea Frequent vomiting Abdominal pain Black, tarry stools or blood in stools Diarrhea Hepatitis

GENITOURINARY

Difficulty voiding Difficulty controlling urine Getting up at night often to void Impotence Pain or problems during sexual intercourse

NEUROMUSCULAR

Frequent headaches Seizures

Any episodes of numbness or paralysis Any episodes of visual loss Stroke

Migraine headaches

Frequent episodes of joint pain or swelling

Severe low back pain

Calf of leg pain with walking

GENERAL

Bleeds or bruises easily

Any difficulty with operations or dental work Any change in mood Trouble sleeping Experienced any new major stresses Lack of energy Any difficulty with alcohol or drugs Thought you should cut down on your drinking of alcohol Feeling down, depressed, or hopeless Any changes in your skin- rashes, itching

FAMILY HISTORYHave any of your relatives had…

Aunt/Grand

FatherMotherBrotherSisterUncleParentChildComments

Heart disease

High blood pressure

Stroke

Kidney disease

Breast cancer

Prostate cancer

Colon cancer

Psychiatric illness

Anemia

SOCIAL HISTORY

Do you use tobacco? How much and for how long?

Do you use alcohol? How much and for how long?

Education:

Vocation: Still working?

Are you exposed to toxins?

Physician’s Signature Date

Revised10/03/2018