MGH Beacon Hill Primary Care New Patient Form
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- Madeline Bennett
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1 MGH Beacon Hill Primary Care New Patient Form For Office Use Only Date Reviewed By Name Date of birth Medical History Please check all that apply. Alcoholism Angina or heart attack Anorexia/bulimia Arthritis Asthma Back pain Blood clots Blood disorder/anemia Blood transfusion ( ) Brain injury Cancer (including skin cancer) Cholesterol elevation Depression Diabetes Drug abuse Emphysema Gynecological disorder (e.g., uterus, ovary) Hay fever Headaches Heart disease HIV disease Intestinal disorder Heart murmur High blood pressure HIV disease Intestinal disorder Intravenous drug use Kidney disease/stones Liver disease or hepatitis Loss of consciousness/seizures Mental illness Mitral valve prolapse Migraines Osteoporosis Pneumonia Prostate disorder Rheumatologic disorders (e.g., RA, lupus) Sexually transmitted diseases Stroke Thyroid problem Tuberculosis Ulcers/gastritis Other: Where have you received medical care most recently? Please indicate any specific concerns about your health.
2 Please list any other major problems for which you have been under a doctor s care in the past. Surgical History Year Procedure Year Procedure Immunizations/Health Screens Date (month/day/year) Chickenpox Hepatitis B (series of 3) Colonoscopy Measles (MMR) Dental exam Pneumococcal Bone density Sigmoidscopy Eye exam/glaucoma Tetanus shot Flu shot TB test Hepatitis A (Havrix) Date (month/day/year) Current Medications (including non-prescriptions, such as herbs) Prescription name Dosage Frequency Allergies Medication allergies Reaction Food/other allergies Reaction
3 Family History Please list the age and health status (excellent, good, fair, poor or deceased) for the following relatives. Mother Father Siblings Children Age Health status Please indicate if a blood relative has had any of the following. If yes, indicate his or her relationship to you (e.g., maternal aunt). Alcoholism Asthma Cancer (indicate type) Diabetes High blood pressure Heart disease Mental illness/depression Migraines Kidney disease/stones Osteoporosis Stroke Thyroid disease Ulcer disease Yes Family relationship Lifestyles and Health Habits Do you currently smoke cigarettes? Yes Number of cigarettes per day Have you ever tried to quit? Yes Are you interested in quitting? Do you drink alcohol? Yes Average number of drinks per week (5 oz. glass of wine = 1 drink) Has drinking ever been a concern for you? Yes How many caffeinated beverages (coffee, tea, cola, etc.) do you drink per day? Have you ever used recreational or illegal drugs? Yes Do you follow a special diet? Yes How many servings of fruits and vegetables do you eat per day?
4 Do you exercise regularly? Yes Do you have trouble sleeping? Yes Does your health make it hard to maintain your daily activities? Yes Do you use seatbelts? Yes Do you use sunblock? Yes Review of Systems Please indicate if you are having concerns about any of the following conditions: General Fever Weight loss Weakness Fatigue Pain Bleeding Lumps Growths Trouble sleeping Eyes Vision problem Redness Excess tears Ears Hearing problem Popping Stuffiness Mouth Tooth problem Difficulty chewing Heart and Lungs Abnormal heart beats Cough Snoring Wheezing Gastrointestinal Difficulty swallowing Heartburn Diarrhea Constipation Blood in stool Black stool Excess gas Genitourinary Difficulty urinating Frequent urination Loss of urine Sexual problem Musculoskeletal Swollen joint Stiff joint Back trouble Neck trouble
5 Skin Rash Unusual mole Acne Itch Neurologic Numbness Shakiness Difficulty walking Emotional Sadness Anxiety Unusual thoughts Other emotional problems Endocrine Excessive hunger Excessive thirst Heat sensitivity Cold sensitivity Hematologic Infection Black and blue marks Other Problems Social History Relationship status: Single Married Divorced Widowed Opposite sex partner Same sex partner Do you live with others? Yes Do you live with children? Yes Are you currently sexually active? Yes If yes, with: Men Women Both Have you ever been in a relationship with a person who hurt or threatened you? Yes Have you ever been in a relationship with a person whom you have hurt or threatened? Yes Do you have any beliefs, values or ideas that your doctor should know about? Yes Is there anything else you would like to discuss today? Yes
6 Gynecological History (Female Patients) Number of: Pregnancies Births Miscarriages Abortions Age of first period Last menstrual period Are they monthly? Yes What birth control method do you/would you use? Frequent vaginal infections? Yes Age at menopause Are you having symptoms of menopause? Yes Last pap smear Last mammogram Please indicate if you have ever had the following: Hot flashes Vaginal dryness Other Abnormal mammogram Abnormal pap smear DES exposure Endometriosis Hormone replacement therapy Uterine fibroids Yes Year Diagnosis
Medical History Form
Medical History Form NAME DOB / / TODAY S DATE MEDICAL HISTORY What medical Conditions do you have? Select all that apply, or write in if not listed: Diabetes High Blood Pressure Thyroid Disorder Heart
Welcome to About Women by Women
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Southern Maine Integrative Health Center Adult Intake Form
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NEW PATIENT QUESTIONNAIRE
NEW PATIENT QUESTIONNAIRE PLEASE PRINT Full name: Age: Preferred Contact number: Email address: Why are you here today? To establish primary care Annual exam Consultation from another doctor If consultation,
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
THE OB/GYN CENTRE NEW PATIENT HISTORY
PERSONAL PROFILE NAME: AGE: NAME YOU WOULD LIKE US TO USE: OCCUPATION: MARITAL STATUS: GYNECOLOGICAL HISTORY LAST MENSTRUAL PERIOD (FIRST DAY): AGE PERIOD BEGAN: PRESENT BIRTH CONTROL PAST METHODS OF BIRTH
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DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)
Medical History: Patient: DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N) List the names of prescription
PATIENT HEALTH HISTORY
Name DOB Sex Age Date MR# PLACE CHARGE TICKET LABEL IN THE DASHED SPACE OR COMPLETE THE ABOVE: PLEASE ANSWER EACH QUESTION AS CORRECTLY AS YOU CAN BY PLACING AN "X" IN APPROPRIATE BOX What is the reason
COMPREHENSIVE NEW PATIENT QUESTIONNAIRE
What brings you in today? What do you prefer to be called (nickname)? Please list all of your medical conditions. 1. 5. 2. 6. 3. 7. 4. 8. What surgical or medical procedures have you had in the past? 1.
FAMILY MEDICINE New Patient Medical History Form
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Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?
PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:
Patient History Form
Patient Personal Information Name: Date: Age: Occupation: Employer's name: Briefly describe your daily activities at work: Sex: male female Marital Status: single married divorced widowed Spouse's name:
Name Age Date. Address Phone. Name of Physician. Address Street Address City State Zip Code
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FOR OFFICE USE ONLY NEW PATIENT ESTABLISHED PATIENT CONSULTATION REPORT SENT: / / OB/GYN COMPREHENSIVE PATIENT INTAKE HISTORY PATIENT NAME: AGE: BIRTHDATE / / DATE: / / RACE: CAUCASIAN AFRICAN-AMERICAN
Address Street Address City State Zip Code. Address Street Address City State Zip Code
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Name Age DOB Sex M F Your relationship status: Single Married Life partner Widowed Address
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Review of Systems NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient,
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