An affiliate of Saint Mary's Health System FRANKLIN MEDICAL GROUP, PC. NEW PATIENT INTAKE FORM. Last Name: First Name: DOB: Age:
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1 FRANKLIN MEDICAL GROUP, PC. NEW PATIENT INTAKE FORM Last Name: First Name: DOB: Age: Date of Service: Present Occupation: Marital Status: Married Divorced Single Widowed Partnered List household Members (name/age): List any Allergies to medicines, foods, insects, etc. with reaction: Lifestyle Review: Please list approximate date of your last: Dental exam: Eye exam: Any problems with hearing? Are you on any special kind of diet? If so, what kind? Do you feel you eat a healthy diet? Do you have any weight concerns? Do you exercise? How often? What type? Do you use tobacco products now or did you smoke in the past Yes No If yes, what type: How many / day? How many years? Age stopped? About how much alcohol do you have on an average day? or week? Do you sometimes use street drugs (cocaine, marijuana, heroin, etc)? Reproductive Health and Cancer Screening: Men: Women: Are you sexually active? When was your last menstrual period? How many partners in the past 5 years? Do you have any problems with periods? Men, women, or both? Are you sexually active? Do you use birth control / contraception? How many partners in the past 5 years? If yes, what type? Men, women, or both? Do you have problems with sex or intercourse? Do you use birth control / Contraception? When was your last prostate screening? If yes, what type? PSA: Exam: Number of pregnancies: Do you examine your testicles for lumps? Date of last colonoscopy: Page 1 of 5 Number of births: Date of last pap smear: Date of last mammogram: Do you check your breast for lumps? Date of last colonoscopy: Date of last bone density test:
2 Risk Screening: Do you always wear seatbelts in a car? Do you wear helmets when appropriate? Do you wear sunscreen when appropriate? Do you have working smoke and carbon monoxide detectors? Do you have any unsecured firearms in your home? Do you have any history of abuse or violence in your home? Do you have problems with stress or anger management? Have you had driving violations? Do you have concerns about your memory? Do you have any work or travel exposures or risks? Yes No Page 2 of 5
3 IF YOU HAVE HAD A PHYSICIAL OR PRVENTATIVE EXAM WITH FRANKLIN MEDICAL GROUP, PC IN THE PAST, PLEASE ONLY RECORD ANY UPDATES OR CHANGES TO YOUR MEDICAL HISATORY IN THIS SECTION. Immunizations Date of last tetanus shot? Has it been more than 10 years? If you re over 65, have you had the pneumonia shot (pneumovax)? Do you get annual Flu (Influenza) vaccine? Have you been exposed to Tuberculosis or had a positive TB test in the past? Have you ever had chicken pox or shingles? Have you had the Hepatitis B Vaccine? Have you had the HPV (Gardasil) Vaccine? If you re over 60, have you had the shingles vaccine? Medical History: CURRENT MEDICINES: List all medications include hormones, birth control pills, eye drops, vitamins, inhalers, creams, nasal sprays, supplements, and over the counter medicines. Check here if none. Name of Medication Dose Times Per Day Name of Medication Dose Times Per Day Page 3 of 5
4 Medical Conditions Check all that apply now or in the past: Alcohol or drug problem Ear Problems Radiation Treatment Allergies / Hay Fever Gallbladder Problem Seizures/Epilepsy Anemia Headaches / Numbness Sexually Transmitted Disease Arthritis / Gout Heart Trouble/Angina/Heart Murmur Sleep Apnea/Sleep Problems Blood Clots / Phlebitis Hepatitis Skin Cancer/Rashes Cancer / Tumor High Cholesterol Stomach or Duodenal Ulcer/Heartburn Colon / Bowel Problem High Blood Pressure Stroke Depression / Anxiety Kidney Problems/Kidney Stones Thyroid Diabetes Liver Disease Urinary/Prostate/Sexual Problems Dizziness Abnormal Mammogram or Pap Lung Problems/Asthma Lyme Disease Page 4 of 5
5 List any specialists you see on a regular basis: LIST ALL HOSPITALIZATIONS, OPERATIONS, (INCLUDING CHILDHOOD), SERIOUS INJURIES, AND ILLNESSES SINCE YOUR LAST PHYSICAL EXAM AT FRANKLIN MEDICAL GROUP, PC YEAR YEAR FAMILY HISTORY: If your Mother (m), Father (f), Sister (s), Brother (b), or Children (c) have any Please list which relative has had the medical problem I don t know my family medical history I am adopted Family Member Family Member Alcohol/Drug Problem Suicide Brest Cancer Osteoporosis Colon Cancer/Polyps Prostate Cancer Diabetes Sickle Cell Anemia Heart Problem Skin Cancer High Blood Pressure Thyroid Problem High Cholesterol Other Cancer Mental Illness/Depression Other Other Page 5 of 5
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