New Patient History Form New Logo

New Patient Inquiry

Dateoffirstappointment: / / Timeofappointment: Birthplace:

MONTHDAYYEAR

Name: Birthdate: / /

LASTFIRSTMIDDLEINITIALMAIDENMONTHDAYYEAR

Address: Age: Sex:‰F ‰M

STREETAPT#

Telephone:Home ( )

CITYSTATEZIPWork ()

MARITALSTATUS: ‰NeverMarried ‰Married ‰Divorced ‰Separated ‰Widowed

Spouse/SignificantOther: ‰Alive/Age ‰Deceased/Age MajorIllnesses

EDUCATION (circlehighestlevelattended):

GradeSchool78910 11 12College1234GraduateSchool Occupation Numberofhoursworked/averageperweek

Referredhereby:(checkone) ‰Self ‰Family ‰Friend ‰Doctor ‰OtherHealthProfessional

MEDICAL HISTORY

As youreviewthe followinglist,pleasecheckanyofthoseproblems,whichhavesignificantlyaffectedyou.

Dateoflastmammogram Dateof lasteyeexam Dateoflastchest x–ray DateoflastTuberculosisTest Dateoflastbonedensitometry

Constitutional

☐Recentweightgain

amount

☐Recentweightloss

amount

☐Fatigue

☐Weakness

☐Fever

Eyes

☐Pain

☐Redness

☐Lossof vision

☐Doubleorblurredvision

☐Dryness

☐Feelslikesomethingineye

☐Itchingeyes

Ears–Nose–Mouth–Throat

☐Ringingin ears

☐Lossof hearing

☐Nosebleeds

☐Lossof smell

☐Drynessin nose

☐Runnynose

☐Soretongue

☐Bleedinggums

☐Soresinmouth

☐Lossof taste

☐Drynessofmouth

☐Frequentsorethroats

☐Hoarseness

☐Difficultyin swallowing

Cardiovascular

☐Paininchest

☐Irregularheartbeat

☐Suddenchangesinheartbeat

☐Highbloodpressure

☐Heartmurmurs

Respiratory

☐Shortnessofbreath

☐Difficultyin breathingat night

☐Swollenlegsorfeet

☐Cough

☐Coughingof blood

☐Wheezing(asthma)

Gastrointestinal

☐Nausea

☐Vomitingofbloodorcoffeegroundmaterial

☐Stomachpainrelievedbyfoodormilk

☐Jaundice

☐Increasingconstipation

☐Persistentdiarrhea

☐Bloodinstools

☐Blackstools

☐Heartburn

Genitourinary

☐Difficulturination

☐Painorburningonurination

☐Bloodinurine

☐Cloudy,“smoky”urine

☐Pusin urine

☐Dischargefrom penis/vagina

☐Gettingupat nightto passurine

☐Vaginaldryness

☐Rash/ulcers

☐Sexualdifficulties

☐Prostatetrouble

ForWomenOnly:

Agewhenperiodsbegan:Periods regular?☐Yes☐No

Howmanydaysapart?

Date oflastperiod? ______

Dateoflastpap? ______

Bleedingaftermenopause?☐Yes☐No Numberofpregnancies?

Numberofmiscarriages?

Musculoskeletal

☐Morningstiffness

Lastinghowlong?

Minutes Hours

☐Jointpain

☐Muscleweakness

☐Muscletenderness

☐Jointswelling

Listjointsaffectedinthelast6mos.

Integumentary(skinand/orbreast)

☐Easybruising

☐Redness

☐Rash

☐Hives

☐Sunsensitive(sunallergy)

☐Tightness

☐Nodules/bumps

☐Hair loss

☐Colorchangesofhandsorfeet in the cold

NeurologicalSystem

☐Headaches

☐Dizziness

☐Fainting

☐Musclespasm

☐Lossof consciousness

☐Sensitivityorpainofhandsand/orfeet

☐Memoryloss

☐Nightsweats

Psychiatric

☐Excessiveworries

☐Anxiety

☐Easilylosingtemper

☐Depression

☐Agitation

☐Difficultyfallingasleep

☐Difficultystayingasleep

Endocrine

☐Excessivethirst

Hematologic/Lymphatic

☐Swollenglands

☐Tenderglands

☐Anemia

☐Bleedingtendency

☐Transfusion/when

Allergic/Immunologic

☐Frequentsneezing

☐Increasedsusceptibilityto infection

SOCIALHISTORY

Do youdrinkcaffeinatedbeverages?

Cups/glassesperday?

Doyousmoke?☐Yes☐No☐Past– Howlongago?

Doyoudrinkalcohol?☐Yes☐NoNumberperweek

Has anyoneevertoldyoutocutdownon yourdrinking?

☐Yes☐No

Do youusedrugsforreasonsthatarenotmedical?☐Yes☐No

Ifyes,pleaselist:

Do youexerciseregularly?☐Yes☐No

Type

Amount perweek

Howmanyhoursofsleepdoyougetatnight?

Do yougetenoughsleepat night? ☐Yes☐No

Do youwakeupfeelingrested? ☐Yes☐No

PASTMEDICALHISTORY

Do younoworhaveyoueverhad: (checkif “yes”)

☐Cancer☐Heartproblems☐Asthma

☐Goiter☐Leukemia☐Stroke

☐Cataracts☐Diabetes☐Epilepsy

☐Nervousbreakdown☐Stomach ulcers☐Rheumaticfever

☐Bad headaches☐Jaundice☐Colitis

☐Kidney disease☐Pneumonia☐Psoriasis

☐Anemia☐HIV/AIDS☐High Blood Pressure

☐Emphysema☐Glaucoma☐Tuberculosis

Othersignificantillness(pleaselist) ______

NaturalorAlternativeTherapies(chiropractic,magnets,massage, over-the-counterpreparations,etc.)

______

Previous Operations

Anypreviousfractures?☐No☐Yes Describe:Anyotherseriousinjuries?☐No☐Yes Describe:

FAMILYHISTORY:

Numberofsiblings Numberliving Numberdeceased

Numberof children Numberliving Numberdeceased Listagesof each Healthofchildren:

Do youknowof anybloodrelativewhohasorhad:(checkandgiverelationship)

☐Cancer

☐Leukemia

☐Stroke

☐Colitis

☐Heartdisease

☐Highbloodpressure

☐Bleedingtendency

☐Alcoholism

☐Rheumaticfever

☐Epilepsy

☐Asthma

☐Psoriasis

☐Tuberculosis

☐Diabetes

☐Goiter

MEDICATIONS

Drugallergies:☐No☐YesTowhat?

Typeofreaction:

PRESENTMEDICATIONS (List anymedicationsyouaretaking. Includesuchitemsasaspirin,vitamins,laxatives, calciumandothersupplements, etc.)

PASTMEDICATIONSPleasereviewthis listof “arthritis”medications.As accuratelyaspossible,tryto rememberwhichmedicationsyou have taken,howlongyouweretakingthemedication,theresults of takingthemedicationand listanyreactionsyoumayhavehad.Recordyour commentsin thespacesprovided.

Haveyouparticipatedinanyclinicaltrialsfornewmedications?☐Yes☐No

If yes,list:

ACTIVITIESOFDAILYLIVING

Doyouhavestairstoclimb? ☐Yes ☐NoIfyes,howmany?

Howmanypeopleinhousehold? Relationshipandageof each

Whodoesmostof thehousework? Whodoesmostof theshopping? Whodoesmostof theyardwork?

On thescalebelow,checkwhichbest describesyoursituation;Mostofthetime,Ifunction…

Becauseof healthproblems,do youhavedifficulty:

(Pleasecheckthe appropriateresponseforeachquestion.)

Whatisthe hardestthingforyoutodo?