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WELCOME TO OUR PRACTICE. AS A NEW PATIENT, PLEASE FILL OUT THE
INFORMATION FOUND BELOW TO THE BEST OF YOUR ABILITY.
Patient Name: __________________________________ Date: __________________________
Chief Complaint: _______________________________
Birth date: ___________________________
History of present illness:
Location: ___________________________________________
Quality: _____________________________
(Where is the pain/problem?)
(Ex: normal vs. abnormal color, activity, etc.)
Severity: ______________________________________
Duration: ____________________________
(How severe is the pain/problem on a scale of 1-5 with 5
being the most severe)
Timing: _______________________________________
(How long have you had this pain/problem
Or, when did it start?)
Context: ____________________________
(Does the pain/problem occur at a specific time?)
(Where were you at the onset of this pain
problem?)
Associated signs/symptoms: _______________________ Modifying Factors: ___________________
_______________________________________________ ____________________________________
(What other associated problems have you been having?)
(What makes the pain/problem worse or better? Or,
have you had previous episodes?)
Past Medical History
Have you ever had the following:
Measles
Mumps
Chicken pox
Whooping Cough
Scarlet Fever
Diphtheria
Smallpox
Pneumonia
Rheumatic Fever
Heart Disease
Arthritis
Venereal Disease
Hepatitis
Thyroid Disease
Any other disease
(Please list)
(Circle “no” or “yes”, leave blank if uncertain)
no yes Anemia
no yes Back trouble
no yes
no yes Bladder Infections
no yes High Blood Pressure no yes
no yes Epilepsy
no yes Low Blood Pressure
no yes
no yes Migraine Headaches no yes Hemorrhoids
no yes
no yes Tuberculosis
no yes Date of last Chest X-ray _______
no yes Diabetes
no yes Asthma
no yes
no yes Cancer
no yes Hives or Eczema
no yes
no yes Polio
no yes AIDS or HIV+
no yes
no yes Glaucoma
no yes Infectious Mono
no yes
no yes Hernia
no yes Bronchitis
no yes
no yes Blood or Plasma
no yes Mitral Valve Prolapse no yes
no yes Transfusions
no yes Stroke
no yes
no yes Ulcer
no yes Kidney Disease
no yes
no yes Bleeding Tendency
no yes
no yes
______________________________________________________________________________
Previous Hospitalizations/Surgeries/Serious Illnesses
When?
Hospital/City/State
___________________________________________
_______
____________________
___________________________________________
_______
____________________
___________________________________________
_______
____________________
Medications: (Include nonprescription)
_____________________________________________________________________________________
_____________________________________________________________________________________
Have you ever taken Phen-Fen/Redux?
no yes
Patient Social History
Marital Status
Use of Alcohol
Use of Tobacco
Use of Drugs
Single_____
Never _____
Never _____
Never _____
Married _____ Separated_____ Divorced_____ Widowed______
Rarely ______ Moderate _____ Daily _______
Previously but Quit __________
Type/Frequency ___________________________________________
Family Medical History
Father
Mother
Siblings
Spouse
Children
Age
_______
_______
_______
_______
_______
_______
_______
Diseases
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
If Deceased, Cause of Death
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
______
______
_______________________
_______________________
_________________________
_________________________
HEALTH HISTORY