Download New patient medical history 2

NEW PATIENT INFORMATION FORM
Today’s date:________________________________________
Patient’s Name:______________________________________DOB:_______________________AGE:__________
Primary Care Provider’s Name:_____________________ Preferred Pharmacy:_____________________________
What is the reason for today’s visit?_______________________________________________________________
PAST MEDICAL HISTORY
(Please circle all that apply)
Asthma/Allergies
Pneumonia/Lung infection
Kidney infection/stone
High Cholesterol
Heart attack/problems
Mitral Valve Prolapse
High blood pressure
Rheumatic fever
Blood clots in legs or lungs
Diabetes
Thyroid disease
Reflux/hiatal hernia/ulcers
Bowel problems
Hepatitis/Liver disease
Anemia
Blood transfusions
Seizures/convulsions/epilepsy
Headaches, Migraines
Anxiety
Depression
Eating disorder
Addiction
Glaucoma
Arthritis/joint pain
Back problems
Fibromyalgia
Osteoporosis
Cancer (Please Specify)____________________
Other:____________________________________________________________________________________
__________________________________________________________________________________________
FAMILY HISTORY
( Please list all health issues known for each family member)
Mother_____________________________________________________________________________________
Father______________________________________________________________________________________
Siblings_____________________________________________________________________________________
Maternal grandmother_________________________________________________________________________
Maternal grandfather__________________________________________________________________________
Paternal grandmother__________________________________________________________________________
Paternal grandfather___________________________________________________________________________
Children_____________________________________________________________________________________
Breast Cancer_________________
Colon Cancer___________
Ovarian Cancer________________
Uterine Cancer_________________
SURGICAL HISTORY: Please list all surgeries you have had:
YEAR_________________Surgery______________________________________________________________
YEAR_________________Surgery______________________________________________________________
YEAR_________________Surgery______________________________________________________________
YEAR_________________Surgery______________________________________________________________
YEAR_________________Surgery______________________________________________________________
Have you had a Hysterectomy?:_________ Was it Vaginal, Abdominal, or Laparoscopic?__________________
What was the reason for the Hysterectomy?:______________________________________________________
HOSPITALIZATIONS: (Other than surgery or childbirth)
YEAR_________________Reason_______________________________________________________________
YEAR_________________Reason_______________________________________________________________
YEAR_________________Reason_______________________________________________________________
YEAR_________________Reason_______________________________________________________________
OBSTETRIC HISTORY:
Number of pregnancies_____________________
Number of living children:____________________
Still Births___________________________
Miscarriages________________________________
Full term births_______________________
Premature births (<36 weeks) ___________
Ectopic Pregnancies___________________
Pregnancy Terminations________________
Year:_______ Type of pregnancy/delivery: _______________________________Infant weight:____________
Complications:_____________________________________________________________________________
Year:_______ Type of pregnancy/delivery: _______________________________Infant weight:____________
Complications:_____________________________________________________________________________
Year:_______ Type of pregnancy/delivery: _______________________________Infant weight:____________
Complications:_____________________________________________________________________________
Year:_______ Type of pregnancy/delivery: _______________________________Infant weight:____________
Complications:_____________________________________________________________________________
Year:_______ Type of pregnancy/delivery: _______________________________Infant weight:____________
Complications:_____________________________________________________________________________
GYNECOLOGIC HISTORY:
Age at first period_______________
If you menstruate:
First day of last period_______ How often do you get your period?____________(days)
How long does your period last?______ On the heaviest day, how many pads or tampons do you use?______
Age at Menopause_______________
Have you ever had sex?_______________ Age at time of first sexual intercourse_________________________
Do you have sex now?________________How many partners have you had in your life?__________________
How many sexual partners in the last year?_______________________________________________________
Sexual partners are:
Men______ women______ both______
Present method of birth control:_______________________________________________________________
Have you ever had:
Chlamydia
Herpes
HIV
Gonorrhea
Trichomonas
HPV/Venereal warts
Syphilis
Have you ever been screened for HIV?_____________ When?________________________
Have you ever had an abnormal PAP smear?_________When?________________________
ALLERGIES:
To What:______________________________Reaction:_____________________________________________
To What:______________________________Reaction:_____________________________________________
To What:______________________________Reaction:_____________________________________________
To What:______________________________Reaction:_____________________________________________
To What:______________________________Reaction:_____________________________________________
MEDICATIONS/SUPPLEMENTS/HERBAL PRODUCTS:
Name:_____________________Dose/Frequency:__________________________________________________
Name:_____________________Dose/Frequency:__________________________________________________
Name:_____________________Dose/Frequency:__________________________________________________
Name:_____________________Dose/Frequency:__________________________________________________
Name:_____________________Dose/Frequency:__________________________________________________
Name:_____________________Dose/Frequency:__________________________________________________
Name:_____________________Dose/Frequency:__________________________________________________
Name:_____________________Dose/Frequency:__________________________________________________
Name:_____________________Dose/Frequency:__________________________________________________
Name:_____________________Dose/Frequency:__________________________________________________
Name:_____________________Dose/Frequency:__________________________________________________
Name:_____________________Dose/Frequency:__________________________________________________
Name:_____________________Dose/Frequency:__________________________________________________
Name:_____________________Dose/Frequency:__________________________________________________
Name:_____________________Dose/Frequency:__________________________________________________
SOCIAL HISTORY:
Tobacco
Yes
No
Packs per day________ how long?___________ quit date:__________
Alcohol
Yes
No
Drinks per day________Per week_____________Per year____________
Drug use
Yes
No
Types______________________________________________________
Exercise
Yes
No
What type__________________________________________________
Seat belt use Yes
No
___________________________________________________________
Have you been: (please circle)
Threatened:
No
Yes
Now In the past
Injured:
No
Yes
Now In the past
Sexually abused:
No
Yes
Now In the past
Made to feel afraid by anyone:
No
Yes
Now In the past
PERSONAL PROFILE:
Marital status:
Married
Divorced
Widowed
Living with partner
Single
Who lives in your household?_____________________________________________________________________
What is/was your occupation:_____________________________________________________________________