Download New Patient Form

. Richardson New Patient Form
Please fill out as much of the information as you can.
Patient Name: _______________________
Date of Birth: _______________________
Date of Service: _____________________
Past Medical & Surgical History: (List all medical problems current and past, including surgeries and dates. Pediatric
patients, include birth history – such as; maternal labs, medications taken, prematurity, birth weight, jaundice, etc.)
1. ______________________________
5. ________________________________
2. ______________________________
6. ________________________________
3. ______________________________
7. ________________________________
4. ______________________________
8. ___________________________(use back of sheet if necessary).
Medications: (List all medications and dosage you are taking. Skip if you have a list with you).
1. ______________________________
5. ________________________________
2. ______________________________
6. ________________________________
3. ______________________________
7. ________________________________
4. ______________________________
8. ___________________________(use back of sheet if necessary).
Allergies: (List all allergies (and the reaction you had), include allergies to medicines and environmental/foods).
___________________________________________________________________________________
Family History: (Please include all medical problems, the age their problems started, and if deceased what they died
from and at what age).
Father: _______________________________________________________________________
Mother: ______________________________________________________________________
Dad’s Father: __________________________________________________________________
Dad’s Mother: _________________________________________________________________
Mom’s Father: _________________________________________________________________
Mom’s Mother: ________________________________________________________________
Patient’s Siblings: ______________________________________________________________
Children: _____________________________________________________________________
Do you have a family history of sudden cardiac death in a family member less than 40 years of age?
___________________________
Social History:
Date (and result if applicable) of last:
Do you smoke or have you ever smoked? __________________________
Flu Shot: _______________________
If yes: How much do you smoke? _________________________
Pneumonia Shot: _________________
What age did you start? ____________________________
Colonoscopy: ____________________
If you quit, how long ago was it? ____________________
Pap: ____________________________
Do you drink alcohol? __________________________________________
Mammogram: ____________________
If yes: How much, and what do you drink? __________________
Bone Density: ____________________
Do you use street drugs? _________________________________________
What is your occupation? ________________________________________
Are you married or single? _______________________________________
Who do you live with? __________________________________________
Are you able to care for yourself? _________________________________
Do you need assistance to get around, like a cane or walker? ____________
Do you have any pets? ________ If yes, what? ______________________