New Patient Health History Questionnaire

New Patient Health History Questionnaire

Please fill out this health history questionnaire thoroughly and specifically. It is important information which will enable us to spend time discussing your medical condition. It will become part of your medical record and will remain confidential. Thank you.

Name: ______DOB: ______Age: ______Date: ______

Primary Care Physician: ______Referring Physician: ______

Reason for today’s visit/Problems to discuss with the doctor: ______

______

What surgeries have you had? Please be as specific as possible.

Month/Year / Surgery / Any Complications?

What medications are you currently taking? Please include vitamins and over-the-counter medications.

______

What medications are you allergic to? What reaction does it cause?

______

What medical problems have you had in the past? Please explain specifically.

High Blood Pressure / Hepatitis or Liver Disorders
Heart Disease / Kidney Stones
Cholesterol Problems / Kidney Disease
Blood Clots / Seizures
Anemia or Blood Disorders / Migraine Headaches
History of Blood Transfusions / Neurological Disorders
Diabetes / Depression or Psychiatric Disorders
Thyroid Disorders / Cancer
Asthma / Birth Defects
Tuberculosis / Anesthesia Complications
Lung Disorders / Infertility
Stomach or Bowel Disorders / Abnormal Pap Smear
Other problems:

Social History

What is your current marital status? Single Married DivorcedWidowedEngaged

Do you smoke? Yes NoIf yes, how much per day?______How long have you smoked? ______

If a non-smoker, have you smoked in the past? Yes No

Do you drink alcoholic beverages?YesNoHow often?______

Do you use recreational drugs?YesNoHow often?______

Family History

Breast CancerWhat relation?______Age of onset: ______

Ovarian Cancer What relation?______Age of onset: ______

OsteoporosisWhat relation? ______Age of onset: ______

Colon CancerWhat relation?______

DiabetesWhat relation?______

Heart DiseaseWhat relation?______

High Blood PressureWhat relation?______

Gynecological History

When was your last Pap Smear? ______Was it normal?Yes No

When was the first day of your last period? ______Was it normal? Yes No

How old were you when you began having periods? ______

How often do you have periods? ______How long do they last? ______

Are they irregular?Yes NoAre they painful? YesNo

Are you sexually active?YesNo

Have you had multiple sexual partners in the recent past?YesNo

Have you been exposed to or had Sexually Transmitted Diseases?YesNo

What birth control do you currently use? ______

If menopausal, how old were you when it began? ______

Childbirth History

How many times have you been pregnant? ______How manychildren are still living? ______

How many were born full term? (more than 37 weeks) ______How many were early? (less than 37 weeks) ______

How many abortions? ______How many miscarriages? ______How many tubal pregnancies? ______

Please explain each pregnancy, including pregnancy losses. List specific complications like: Pre-term labor, Still Born, Birth Defects of baby, High Blood Pressure, Diabetes, Other.

No / Date of Birth / How many weeks pregnant? / Weight / Sex / Vaginal or C-Section? / Epidural? / Complications? / Location
1
2
3
4
5
6
7
8
9
10

ONLY if you are currently pregnant, complete the next section.

Have any of these occurred duringthis pregnancy?

Smoking / Abdominal Pain
Alcohol Use / Vaginal Bleeding/Odor
Street/Illicit Drug Use / Over the Counter Medications
Fever / Vomiting
Rash or Viral Illness / Do you have cats?
Prescription Medications

Have any of these occurred in your family or the baby’s father’s family?

Mediterranean (Italian, Greek) or Oriental backgroundWhatrelation? ______

Neural Tube Defect (Spina Bifida, Anencephaly)What relation? ______

Ashkenazi Jewish (Tay-Sachs)What relation? ______

Sickle Cell Disease/TraitWhat relation? ______

Huntington’s ChoreaWhat relation? ______

Birth DefectsWhat relation? ______

Down SyndromeWhat relation? ______

HemophiliaWhat relation? ______

Muscular DystrophyWhat relation? ______

Cystic FibrosisWhat relation? ______

Mental RetardationWhat relation? ______

Other hereditary diseasesWhat relation? ______