PATIENT INFORMATION Last Name: First Name: Middle: Date of Birth: EMERGENCY CONTACT INFORMATION PRIMARY INSURANCE INFORMATION
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1 PATIENT INFORMATION Last Name: First Name: Middle: Date of Birth: Gender: SSN: Race: Marital Status: Address Line: City: State: Zip Code: Home Phone: Work Phone: Address: Cell Phone: Primary Care Physician: EMERGENCY CONTACT INFORMATION First Name: Middle: Last Name: Address Line: City: State: Home Phone: Relationship: PRIMARY INSURANCE INFORMATION Insurance Name: Policy Number: Group Number: Subscriber: Relationship: Date of Birth: SSN: SECONDARY INSURANCE INFORMATION Insurance Name: Policy Number: Group Number: Subscriber: Relationship: Date of Birth: SSN: PHARMACY INFORMATION Pharmacy Name: Address: Phone Number: RELEASE OF INFORMATION Due to HIPPA Regulations we are unable to give information such as biopsy and lab results to anyone not listed on this form. Please list the following people you give consent for your information to be given to: NAME RELATIONSHIP Page 1 of 6
2 HEALTH INFORMATION Reason for Visit: How were you referred to us: Approximate date in which you were first aware of this problem: [ ]Don t remember [ ] several years ago [ ] several months ago [ ] several days ago HISTORY OF RECENT HOSPITALIZATIONS AND SURGERIES TYPE YEAR TYPE YEAR ALLERGIES TO DRUGS OR OTHER SUBSTANCES ALLERGY TO REACTION TYPE ALLERGY TO REACTION TYPE Type, strength and times taken per day MEDICATIONS Type, strength and times taken per day Medication Dose How Often Patient Name: DOB: Page 2 of 6
3 Do you live alone? [ ] Yes [ ] No Occupation: Education: Do you have children: [ ] Yes [ ] No If yes, how many: How much alcohol consumption: Do you smoke cigarettes or cigars? Packs per day: For how many years: How often do you exercise: Number of caffeinated drinks per day: [ ] Tea [ ] Coffee [ ] Soft Drinks [ ] Energy Drinks What is your current height? SOCIAL HISTORY HEIGHT AND WEIGHT What is your current weight? Recent weight GAIN? If so, how many pounds? Recent weight LOSS? If so, how many pounds? Personal Review of Systems Change in appetite Yes No Change in diet Yes No Fever or Shaking Chills Yes No Night sweats Yes No Severe sweating Yes No Problems sleeping Yes No Muscle Weakness Yes No Fatigue Yes No Swollen glands/ lymph nodes Yes No Increased thirst Yes No Hot flashes Yes No Bruise easily Yes No Hypoglycemic/ low sugar Yes No Bleeding Yes No 10 lb. weight gain/loss in past year Yes Blurred/ double vision Yes No No Cataracts/ Glaucoma Yes No Hearing loss or ringing in the ears Yes No Sore throat/ hoarseness Yes No Nose bleeds Yes No FAMILY MEDICAL HISTORY Are you adopted? Yes No Father living: [ ] Yes [ ]No Current age (or age of death) List cause of death: Mother living: [ ] Yes [ ] No Current age (or age of death) List cause of death: Patient Name: DOB: Page 3 of 6
4 Gastro/Internal Med Section Nausea Yes No Vomiting blood Yes No Blood in your bowel movements Yes No Frequent diarrhea Yes No Frequent constipation Yes No Stomach pains Yes No Frequent heartburn/ indigestion Yes No Difficulty swallowing solid foods, liquids or pills Yes No Recent change in bowel habits Yes No Anemia Yes No Fecal incontinence/ uncontrollable bowels Yes No Abdominal bloating Yes No Excessive burping Yes No Black tarry stools Yes No Excessive gas Yes No Frequent vomiting Yes No Have you ever had a colonoscopy? Yes No If yes, what were the results Jaundice Yes No Hepatitis A Yes No Hepatitis B Yes No Hepatitis C Yes No Pain/ stiffness/ swelling in joints Yes No Page 4 of 6
5 Gastro/Internal Med Section cont. Have you ever coughed up blood Yes No Diabetic Yes No Shortness of breath Yes No Wheezing/ Asthma Yes No Recurrent chest pains Yes No Rapid/ irregular heartbeat Yes No Abnormal swelling in legs or feet Yes No Pain when urinating Yes No Difficulty urinating Yes No Thyroid disease {hypothyroid/ hyperthyroid} Yes No Sleep disrupted for frequent trips to bathroom Yes No Stone or kidney problems Yes No High blood pressure Yes No High cholesterol Yes No Valvular or Coronary Artery Disease Yes No Osteoporosis/ Osteopenia Yes No Page 5 of 6
6 Siblings Mother Father Grandparent Heart disease Diabetes High blood pressure Required to carry an Epi-Pen Had trouble with anesthesia during a surgery Depression Breast Cancer Colon Cancer Lung Cancer Colon Polyps Prostate Cancer Leukemia Lymphoma/Hodgkin s Unknown/Other type Page 6 of 6
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