NEW PATIENT HISTORY AND PHYSICAL FORM
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- Baldwin Willis
- 6 years ago
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1 Temp: BP: Ht: P: WT: R: NEW PATIENT HISTORY AND PHYSICAL FORM Patient s Name: Age: Sex: Male Female CHIEF COMPLAINT: (why you are here today) History of Present Illness LOCATION of pain / problem? HOW LONG have you had this problem? HOW OFTEN do you have the pain? What makes it WORSE? What makes it BETTER? What ASSOCIATED PROBLEMS have you been having? What is the severity of your pain? Mar an X on the appropriate circle below: (No Pain) (Extreme Pain) What does the pain FEEL like? (throbbing, shooting, sharp, etc.) General Medical Information My General Health Is: (please check one) Excellent Very Good Good Fair Who is your family Doctor: Are you currently pregnant or attempting to get pregnant? Yes No List any medications you are currently taking including strength and how often taken: Name Dosage How Often Name Dosage How Often Are you currently taking (or have you taken in the past) diet pills or herbal supplements? Yes No If Yes, what is the name of the pill/supplement and the date last taken: 1 P age
2 Allergies List any Medications and/or foods that you are ALLERGIC to or have had a bad reaction to: Medication / Food Reaction Name Reaction Past Medical History Check any problem that you have ever been treated for: Alcohol Dependency Angina Arthritis Asthma Bladder Infection Bleeding Tendencies Blood Transfusion Bowel Obstruction Broken Bones Cancer Cataracts Chemotherapy Cirrhosis Convulsions Depression Diabetes Drug Dependency Emphysema Fainting Spells Gall Stones Glaucoma Gout Headaches Head Injury Hepatitis A B C Heart Attack Heart Failure Heart Murmur Hereditary Defects Hiatal Hernia / Reflux HIV / AIDS Hypertension Insomnia Irregular Heartbeat Jaundice Kidney Disease/Failure Lupus Muscle Weakness Myocardial Infarction Osteoporosis Pacemaker Paralysis PVD Pneumonia Polio Recent URI Rheumatoid Arthritis Ruptured Disc Sciatica Seizures Sickle Cell Anemia Significant Weight Loss/Gain Spinal Curvature Steroid Use Stomach Ulcers Stroke Syncope Thyroid Disease Tuberculosis Urinary Retention UTI Valvular Disease Varicose Veins Venereal Disease Surgical / Hospitalization History Type of Surgery Date of Surgery 2 P age
3 Prior Non-Surgical Hospitalizations, Major Illnesses or Injuries Reson ofr Admit Date of Admit Social History Occupation: Marital Status: S M W Dv Sp Are you working now? Yes No If no, when did you last work? Place of Birth: Grade of School Completed: I Live in a: House Apartment Condominium Mobil Home Boat Alcohol Consumption: Type: Beer Wine Hard Liquor None Have you quit? Yes No Frequency: Daily Weekly Monthly Never If Yes, How long? Tobacco Use: Type: Cigarettes Pipe Chew None Have you quit? Yes No How much used daily? For how long? If Yes, How long? Family History Mother: Living: Yes No Age: Condition of Health: If Deceased, cause of death and age of death: Father: Living: Yes No Age: Condition of Health: If Deceased, cause of death and age of death: Have you or any member of your family ever had any of the following? (indicate relative by placing a letter next to the problem) F - Father, M - Mother, GF - Grandfather, GM - Grandmother, B - Brother, S - Sister, C Child, U - Uncle, A - Aunt Cancer High Blood Pressure Heart Disease Heart Attack Diabetes Stroke Arthritis Seizures Tuberculosis (TB) Kidney Problems Hepatitis Asthma Emphysema COPD Lupus HIV / AIDS Osteoporosis Reaction to Anesthesia Lung Problems Back Injury Stomach Problems Ulcers Depression Skin Breakdown 3 P age
4 Symptom / Systems Review GENERAL HEALTH/ CONSTITUTIONAL SYMPTOMS Fatigue Difficulty Sleeping Unexpected Bleeding Fever / Chills Night Sweats HEAD / FACE Headaches Lesions or Scars Reduced Facial Strength Recent Hair Loss Masses Facial Paralysis Scalp Tenderness EYES Blurred or Double Vision Dryness Redness of the Eyes Visual Disturbances Wear Glasses or Contacts Cataracts Glaucoma GASREOINTESTINAL Heartburn or Indigestion Changes in Bowel Movements Rectal Bleeding or Blood in the Stool Painful Bowel Movements Constipation Loss of Appetite Nausea or Vomiting Abdominal Pain Frequent Diarrhea Stomach Pain or Cramps NEUROLOGICAL / PSYCHIATRIC Convulsions or Seizures Frequent / Recurring Headaches Numbness or Tingling Sensation tremors Memory Loss or Confusion Light Headed Loss of Consciousness Feeling Blue Dizziness EARS / NOSE / MOUTH / THROAT Earaches or Drainage Bad Breath or Bad Taste Bleeding Gums Hearing Loss Mouth Sores / Ulcers Frequent Sore Throat Ringing in the Ears Difficulty Swallowing Voice Changes Sinus Infections / Problems Sinus Tenderness Dryness of the Mouth Nosebleeds Hayfever Dentures NECK Masses Tenderness Thyroid Tenderness Vein Distention Swollen Glands in the Neck Pain MUSCULOSKELETAL / EXTREMITIES Back Pain Cold Extremities Difficulty Climbing Stairs Difficulty Walking Joint Pain Joint Stiffness or Swelling Numbness or Tingling Paralysis Walk with a Limp Walk with Assistive Device Walk Only Limited Distances Weakness of Muscles or Joints GENITOURINARY Burning or Painful Urination Blood or Puss in Urine Vaginal Discharge Incontinence or Dribbling Pain with Periods Sexual Difficulty Genital Rash or Ulcers Irregular Periods Testicular Pain Change in Force of Strain Urinating Prostate Problems CHEST / BREAST Breast Discharge Breast Implants Breast Lump Breast Pain CARDIOVASCULAR Chest Pain or Pressure Blood Clots Swelling of Feet and/or Ankles Fast or Irregular Heartbeat Palpitations Swelling of the Hands Heart Trouble Leg Cramps Poor Circulation RESPIRATORY Wheezing Chronic or Frequent Coughs Cough with Mucous Production Difficulty Breathing Dry Cough Shortness of Breath when lying Flat Shortness of Breath when Walking Pain on Breathing Spitting / Coughing up Blood LYMPHATIC / HEMATOLOGIC Bleeding or Bruising Tendency enlarged Glands Phlebitis Slow to Heal After Cuts Other INTEGUMENTARY / SKIN Change in Skin Color Change in Hair or Nails Psoriasis Rash or Itching Skin Nodules or Bumps Skin Changes After Sun Exposure Other 4 P age
5 Please list any other pertinent information that your physicians should know: I hereby attest that I personally completed this form and all information contained herein is true and correct. Signature of Patient or Responsible Party Date Print Name of Patient or Responsible Party HISTORY & PHYSICAL FORM REVIED BY: Print Name of Physician or Physician Assistant DATE: SIGNATURE OF PHYSICIAN OR PHYSICIAN ASSISTANT: 5 P age
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NEW PATIENT INFORMATION FORM
UNIT NUMBER PT. NAME UCSF Medical Center AMBULATORY SERVICES BIRTHDATE LOCATION DATE Today s Date / / What is the reason for your visit today? Where have you been receiving your medical care? Name of Physician
The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.
Rheumatology (circle location of appointment) 111 Hundertmark Rd. Suite 115N 560 S. Maple St. Suite 400 place patient label here Chaska, MN 55318 Waconia, MN 55387 952-361-2450 952-361-2450 The information
5210 E Farness Drive P: (520) Tucson, AZ F: (520) E:
Personalized HealthC are Patient Registration 5210 E Farness Drive P: (520) 795-4100 Tucson, AZ 85712 F: (520) 795-4224 E: www.phcoftucson.com First Name Middle Last Name DOB Age Sex SSN Race Ethnicity
MEDICAL ASSESSMENT PART 1 - SOCIAL HISTORY
Smoking history Alcohol history Never Quit Never Quit PART 2 - MEDICAL HISTORY Date of last colonoscopy? Date of last mammogram? Date of last pap smear? Date of last flu vaccine? Date of last pneumonia
Eastern Body Therapy
2310 Eastern Body Therapy 6th Avenue San Diego, CA 92101 (619)772-4002 Personal Information Name Date of injury/illness Address: Apt. City State Zip Home phone: ( ) Work Phone: ( ) E-mail: Social Security
Scottsdale Family Health
Please list pharmacy you would like us to use for your medications. Pharmacy Phone Number Fax Number Since your last visit: 1. Have you been diagnosed with any new medical conditions? Yes No If Yes (give
Patient Information Last Name: First Name: Middle Initial: Address: City: State: Zip Code:
Patient Information Last Name: First Name: Middle Initial: Address: City: State: Zip Code: Date of Birth (MM/DD/YY): Social Security #: Sex: Male Female Home Phone #: Mobile Phone #: Email Address: Marital
Bridges Family Wellness PC. New Patient Intake. Bridges Family Wellness Intake Form SE Lake Rd, Suite 102 Milwaukie, OR
New Patient Intake Bridges Family Wellness Intake Form Full Name: * What is your birthdate? MM/DD/YYYY * What is your gender identity? * Home address: * Cell Phone * Other Phone number(s): Emergency Contact
NEUROLOGICAL SURGERY, P.C.
NEUROLOGICAL SURGERY, P.C. PATIENT INFORMATION Name Date of Birth Age Address City Sate NY Zip Home ( ) - Cell ( ) - Work ( ) - Ext: Email Address _ Sex M F Soc. Sec. #: / / Single Married Widowed Separated
SURGERY SPECIALTY PATIENT HEALTH HISTORY
SURGERY SPECIALTY PATIENT HEALTH HISTORY Chief Complaint - Please describe the problem that brings you into the office today: Allergies 1. Do you have any allergies? if so, please list To Medications?
PATIENT MEDICAL HISTORY PATIENT INFORMATION
PATIENT MEDICAL HISTORY PATIENT INFORMATION Name: Referred here by: Self Family Friend Doctor Other Health Professional If Doctor, please give name & address: List doctors seen in the last 24 months: Relative(s)