Download 729G-New Patient Medical History.indd

NEW PATIENT MEDICAL HISTORY
Nevada
ph 515-382-5413
f 515-382-7108
Maxwell
ph 515-387-8815
f 515-387-8817
Slater
Name:
ph 515-685-3960
f 515-685-3961
Zearing
MR No:
ph 641-487-7779
f 641-487-7749
DOB:
PERSONAL HISTORY OF ILLNESS (Check any illness, past or present)
Head injury
Migraine headache
Epilepsy (seizure)
Mental illness
Eye disease
Other:
Year
1.
2.
3.
4.
Asthma
Hay fever
Thyroid disease
Heart disease
High blood pressure
Lung disease
Pneumonia
Stomach ulcers
Liver disease
Kidney disease
Anemia
Diabetes
Alcohol abuse
Venereal disease
Broken bones
Skin trouble
Gout/Arthritis
High cholesterol
Rheumatic fever
Recurrent ear infection
SURGERIES AND HOSPITALIZATIONS
Surgery or reason for hospitalization
Year
Surgery or reason for hospitalization
5.
6.
7.
8.
Are you allergic to any medications?
Any other allergies (latex, rubber, etc.)?
ALLERGIES
Yes
No If yes, what?
FAMILY HISTORY
Is there any history of the following diseases in your family? If yes, indicate which relative.
DISEASE
WHICH RELATIVE
DISEASE
Cancer
Stroke
Diabetes
Asthma/Lung disease
Depression
WHICH RELATIVE
Heart disease
High blood pressure
Tobacco/Alcohol abuse
Reaction to anesthesia
Other:
SOCIAL HISTORY
Married
Widowed
Single
Divorced
Occupation:
Are you in a relationship where you feel unsafe:
Yes
No
Caffeine use:
No
Children:
No
Yes-How many:
(coffee,
tea,
cola)
Exercise:
No
Yes-How often:
Drug use:
No
Yes-How often:
Alcohol use:
No
(Marijuana, LSD, Speed, Heroin, Methamphetamine, etc.)
Tobacco use:
No
Yes
If quit, how long did you smoke?
How much:
Do you have a living will/advanced directives?
Clinic use only: Updated/Review
Form 729G
Rev 02/01/2011
(including beer and wine)
Initial/Date:
Yes
Yes-How much:
Yes-How much:
N/A
Year began:
No
Initial/Date:
Do we have a copy?
Yes
Initial/Date:
Nevada, Maxwell, Zearing, and Slater Medical Clinics are affiliates of Story County Medical Center
No