New Patient Questionnaire. Name DOB Date
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- Ezra Reynolds
- 5 years ago
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1 Medical History (This refers to medical problems that have already been diagnosed or treated. Please explain how this is treated, such as diet, medication, surgery, etc.) Condition Abnormal Pap smear Alcohol or drug problems Alzheimer s/ dementia Anemia Anxiety disorder Asthma Blood clot in leg (DVT) Blood clot in lung (PE) Cancer of breast Cancer of colon Cancer of prostate Cancer of skin, melanoma Cancer of skin, other Cancer of other COPD/ emphysema Depression Diabetes Epilepsy Glaucoma GERD/ Chronic reflux Gout Heart attack/ angina Herpes High blood pressure High cholesterol HIV/AIDS Irritable bowel syndrome Hepatitis Migraines Osteopenia/osteoporosis Rheumatoid Arthritis Stroke Thyroid overactive Thyroid underactive Other condition When was it diagnosed Resolved? How was/is it treated?
2 Surgical History Type of surgery C-section Hysterectomy Gallbladder removal Heart surgery Hernia repair Cataract surgery Knee surgery Hip surgery Back surgery Other surgery Date/ dates Allergies to medications Name of medication Type of reaction (rash, breathing problem etc) Allergies to Food Name of food Type of reaction Medication or food intolerances Name of substance Type of reaction (bloating, headache, fatigue, etc) List all supplements or over the counter medications Name of supplement Strength How often do you take it? Why do you take it?
3 Prescription medications Name of medication Is it a Capsule or tablet or liquid Strength How often is it taken? Family History Family Member If alive, DOB If deceased, age of death Mother Father Siblings Children Condition Breast cancer Colon Cancer Other cancer Diabetes High Blood pressure High cholesterol Stroke Heart attack Osteoporosis Thyroid over or underactive Other inherited conditions Who had this
4 Social History Occupation Main support person/people What do you do for fun? Habits Smoking: Tobacco: Non smoker Former smoker When did you quit? How long had you smoked? Current smoker: how many packs a day Last time you tried to quit Are you interested in quiting now? Y N In the future? Y N How long have you been smoking? Marijuana: non user Former user Current user How much / how often Other marijuana use such as edibles topical Drinking alcohol: Non drinker lifelong Former drinker: when did you quit? Current drinker: how many drinks a day or week? Has anyone suggested that you cut back? Other drugs: Never Current user: what do you use? Do you exercise regularly? Y N What do you do and how often? What time do you go to bed? What time to you wake up? Do you have any sleep issues you want to discuss? Diet: How many times a day do you eat? How many servings of fruit do you typically eat a day? How many servings of vegetables do you typically eat a day? Do you follow any specific type of diet and if so, what is it? Do you have any food issues that you want to discuss? Other physicians/healers involved in your care (such as dermatologist, cardiologist, chiropractor, naturopath, counselor, etc.) Name, specialty How do they care for you
5 Review of Systems (Do you have frequently or have you had any of the following in the past month?) General: Fever Weight loss Night sweats Trouble sleeping Skin: Rash Change in mole Blood: Easy bruising Excessive bleeding Endocrine: Cold intolerance. Heat intolerance. Excessive thirst Eye: Vision changes Blind spots Ears: Ringing Decreased hearing Nose/Mouth: Dental abscess Nosebleeds Nasal congestion Neck: Goiter Chronic pain Breasts: Nipple discharge Pain Lumps Cardiovascular: Chest pain Shortness of breath Leg swelling Palpitations Exercise intolerance Pulmonary: Chronic cough Wheezing Pain with breathing Digestive: Heartburn. Constipation. Diarrhea Abdominal pain. Genitourinary: Recent infection Urination at night time (# ) Difficulty with erections Blood in urine Skeletal: Arthritis. Chronic joint pain Brain and Nerves: Dizziness. Specific weakness Memory loss Tremor. Blackouts, fainting Psychiatric: Eating disorder History physical abuse Anxiety Depression For Women: Date of last period Irregular periods Heavy bleeding Painful intercourse Health maintenance Pneumonia vaccine: Pneumovax Prevnar 13 Last mammogram Last colonoscopy Last bone density/ DXA Last chest x-ray Last Pap smear Last tetanus vaccine Shingles vaccine Childhood vaccines
DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)
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Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):
Name: DOB: Date of Appointment: Please list all doctors you currently see (Primary Care Physician and Specialists i.e. Cardiologist): Please list any medications you currently taking along with dosage
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