NEW PATIENT HEALTH HISTORY

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1 NEW PATIENT HEALTH HISTORY Patient Name Today s Date Age Birth Date Date of last physical examination What is your reason for initial visit? Pharmacy Name & Telephone # NOTE: If you have prior records you would like me to review, please bring or send them to our office a few days PRIOR to your appointment. Please give a brief description of the symptoms you are having, and of how long you have had these symptoms: Please list any other physicians you have seen for this problem in the past, and what treatment you received: Please list any prior hospitalizations which you have had, if any, for this problem: 1

2 Are you right or left handed? Right Left Past Medial History: (please circle) High Blood Pressure Stroke Heart Disease Migraines or recurrent headaches Seizures Cancer (Type ) Thyroid Problems Anxiety Diabetes Pacemaker Lung Disease Kidney Disease Bleeding Problems Head Injury(s) Depression Do you have other medical conditions not listed above? Yes No If yes, please explain all other medical conditions Past Surgical History Please list any previous major surgeries and dates of operations: Type of Surgery Year of Surgery Allergies Please list any drug allergies and any type of allergic reaction that you may have: Drug Reaction(s) Medications Please list all current medications (prescription and over the counter): Medications Strength Number of times per day 2

3 FAMILY HISTORY What illnesses, if any tend to run in your family? (please list EVEN if your parents are deceased) Age Health Problems Father Mother Brothers Sisters Children Social History Education Level-Please indicate the highest grade you have reached: Elementary School College: Post Graduate High School Trade School If you are currently in school, what grade? Are you currently employed? Yes/No If yes, what is your occupation? List average hours you work per day Days per week Hours sleep per night Marital Status: Single Married Divorced Widowed HEALTH HABITS: Amount Frequency Caffeine Tobacco Alcohol Other 3

4 Please circle all that you are CURRENTLY experiencing Constitutional Fever, chills, fatigue Eyes Visual disturbance, discharge, pain, redness, photophobia Ears Nose Mouth Throat Congestion, dental problem, ear discharge, ear pain, facial swelling, hearing loss, sinus pain, sore throat, ringing Respiratory Cough, chest tightness, shortness of breath Cardiovascular Chest pain, palpitations (irregular heart beat), swelling in legs or arms GI Abdominal pain, blood in stool, constipation, diarrhea, nausea, vomiting GU Difficulty urinating, flank pain, frequency, hematuria (blood in urine) Musculoskeletal Joint pain, back pain, joint swelling, muscle pain, neck pain, neck stiffness Psychiatric Behavior problem, confusion, dysphoric mood (depression), hallucinations, nervous/anxious Endocrine Cold intolerance, heat intolerance, excessive thirst Hematology/Lymphatic Swollen lymph nodes, Bruises easily Skin rash, wound Allergic/Immunologic Environmental allergies, food allergies, immunocompromised 4

5 CANCELLATION AND NO SHOW POLICY We are dedicated to helping our patients and appreciate those who value this dedication of time, energy and service. We receive many calls from patients who wish to be seen the same day if possible. Our schedule is often full. As a result, last minute cancellations and no show adversely affect other patients. 24 HOUR NOTICE OF CANCELLATIONS IS APPRECIATED LAST MINUTE CANCELLATIONS Any cancellation made the same day of your appointment time is considered last minute. Life is full of the unexpected. Things may come up and you may need to cancel last minute. It should not be a normal occurrence. Please call as soon as possible to reschedule your appointment. NO SHOWS There is a $25 charge if you no show your appointment. Please call the office as soon as possible to schedule a make-up appointment. 1 st OFFENSE You are human, an apology will do! Please be mindful of our policy. 2 nd OFFENSE Yes, you are still human, but you are in the dog house! Cookies might help us to forgive you better. You do remember the policy, right? 3 rd OFFENSE Jokes aside, you are on probation. We need bare minimum 24 hour notice of a cancellation! Any further offense is an indication that you do not regard our time, energies or the needs of the other patients. A further offense will result in termination of the doctor-patient relationship due to non-compliance. Harsh? Maybe, Fair? More than fair. Your cooperation is greatly appreciated! Laura Bonds, M.D Patient signature Date 5

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