DNA CENTER New Patient Information
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1 DNA CENTER New Patient Information Name Address City State Zip Home Phone Work Cell Phone Social Security Number Date of birth Gender ( Male/Female) Age Please Circle: Hispanic/Latin or Non Hispanic/Latin Please Circle: Asian, Native American, Hispanic, Black, White, Other Primary Language: Emergency Contact Information Name Relationship Address Phone Who Referred You Primary Care Physician What Lab do you use: Pharmacy Located at: Do you have an Attorney: If you have not done so, please provide a copy of your driver s license and insurance
2 NAME: Chief Complaints: When did this start? What have you done for treatment of this condition? Who or Where have you gone to for treatment? Is there a family history of this? Relation: Did this problem result from an injury at work? Date Did this problem result from an accident or fall? Where: What happened: Date: Work Status: Have you continued to work since this condition started? What type of work do you do? Do you need any out of work documentation for your job? CURRENT MEDICATIONS/DOSAGES: ALLERGIES (Agents, Specify Reaction: Allergic to Penicillin? HABITS (Drugs, Alcohol, Tobacco): How Much How Often Tobacco Usage: How Long Years How much per day _ Have you tried Quitting?
3 PAST MEDICAL HISTORY TRAUMA (Broken Bones, Head Injury, etc.): Describe: HOSPITALIZATIONS AND OPERATIONS: Year Hospital Diagnosis FAMILY HISTORY (Circle any that apply): Diabetes Mellitus, Tuberculosis, Cancer, Stroke, Hypertension, Renal Disease, Gout, Arthritis, Bleeding Disorders, Heart Disease, Migraines MOTHER: Age Well/Suffers from Deceased from FATHER: Age Well/Suffers from Deceased from CHILD: Age Well/Suffers from Deceased from CHILD: Age Well/Suffers from Deceased from Current Status Check: GENERAL (Circle Positive Responses): Change in weight or appetite, Problems Sleeping, Night sweats HEMATIC (Blood): Anemia, Excessive bruising CENTRAL NERVOUS SYSTEM: Headaches, Seizures, Dizziness, Tremors, Double Vision, Paralysis, Muscle Weakness
4 EYES: Vision Date of Last Eye Exam: Glasses/Contact Lenses, Glaucoma, Cataracts EARS: Deafness, Infections, Ringing in the Ears NOSE AND THROAT: Sinusitis, Hoarseness, Frequent sore throats BREASTS: Masses, Discharge, Pain RESPIRATORY: Tuberculosis or contact with Tuberculosis, Cough, Change in cough, Wheezing CARDIOVASCULAR: Chest Pain, Heart Attack/Disease, Hypertension, Murmur, Palpitations, Thrombophlebitis, Loss of Consciousness GASTROINTESTINAL: Nausea, Vomiting, Diarrhea, Constipation, Rectal bleeding, Change in Bowel habits, Jaundice, Ulcer/gallbladder disease, Hepatitis URINARY TRACT: Kidney disease, Blood in urine, Frequency in urination, Renal stones GENITO-REPRODUCTIVE SYSTEM: MALE: Venereal disease history, Impotence, Infertility FEMALE (Gynecological History): Age of Menstruation Venereal disease history, Serology Last Pap Results Last Period (Obstetric History): Full-term deliveries Pregnancies Abortions Miscarriages Living Children Contraception Method Hysterectomy? MUSCULOSKELETAL: Joint/Muscle Pain, Arthritis, Rheumatism, Swelling, Redness, Stiffness, Deformity, Muscle Pain ENDOCRINE: Thyroid disease, Goiter, Hormone therapy, Diabetes Mellitus PSYCHIATRIC: Psychiatric Treatment Admission Nervousness, Nervous Breakdown, Depression, Insomnia, Nightmares,
5 Memory Loss
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