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NEW PATIENT INFORMATION NAME ___________________________________________ DATE OF BIRTH ________________ SEX: M / F ADDRESS ________________________________________CITY________________________ STATE________ ZIP___________ HOME PHONE ( CELL PHONE ( ) __________________ WORK PHONE ( ) _____________________ ) _________________ SS #___________________OCCUPATION_______________________ ARE YOU PRESENTLY WORKING? Y / N If No, are you disabled or retired?_________________________ HIGHEST LEVEL OF EDUCATION COMPLETED? _______________ REASON FOR TODAY'S VISIT? _________________________________________________________________ SYMPTOMS HOW LONG? TREATMENTS _______________________________________________________________________________________________ _______________________________________________________________________________________________ PAST SURGICAL PROCEDURES APPROX DATE _______________________________________________________________________________________________ _______________________________________________________________________________________________ OTHER MEDICAL PROBLEMS _________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ FAMILY HISTORY Have any family members (father, mother, grandparents) been diagnosed with any diseases? Y / N (If yes, list below) Relationship Disease Relationship Disease __________________________________________ __________________________________________ __________________________________________ __________________________________________ SOCIAL HISTORY Alcohol Y / N How much/How Often ____________________ # of Years______________ Tobacco Y / N How much/How Often ____________________ # of Years______________ Recreational Drugs Y / N What Kind ____________How Often __________________ # of Years______________ ALLERGIES AND ADVERSE REACTIONS (List all medication, food or other allergies) _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ MEDICATIONS (List prescription and non-prescription medications, nutritional supplements, vitamins, herbal formulas, puffers or inhalers) WHAT KIND? HOW MUCH? HOW OFTEN? ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ASSISTIVE DEVICES: (Such as a walker, wheelchair, home oxygen, etc.) _______________________________________________________________________________________________ _______________________________________________________________________________________________ REFERRING PHYSICIAN_ ______________________________ SPECIALTY____________________________ ADDRESS_ ________________________________________CITY________________________ STATE________ ZIP___________ WORK PHONE ( ) __________________ FAX # ( ) _____________________ PRIMARY CARE PHYSICIAN _ _________________________________________________________________ ADDRESS _________________________________________CITY________________________ STATE________ ZIP___________ WORK PHONE ( ) __________________ FAX # ( ) _____________________ OTHER PHYSICIANS INVOLVED IN YOUR CARE: DOCTOR __________________________________________ SPECIALTY _______________________________ ADDRESS _________________________________________CITY________________________ STATE________ ZIP___________ WORK PHONE ( ) __________________ FAX # ( ) _____________________ DOCTOR __________________________________________ SPECIALTY _______________________________ ADDRESS _________________________________________CITY________________________ STATE________ ZIP___________ WORK PHONE ( ) __________________ FAX # ( ) _____________________
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