General Internal Medicine Clinic - New Patient Questionnaire

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Internal Medicine Associates of Southern New Jersey Robert Schwartz. D.O. University Executive Campus Marc H. Mlchelson. D.O., FAC.O.I. 151 Fries Mill Road,.Suite 400 James C.D'Amico, D.O. Turnersville, NJ 08012 Kim M. Palermo, D.O. Phone: (856) 401 9300 Veronica Rossetti, MSN,APN-C Fax (856) 374--5307 General Internal Medicine Clinic - New Patient Questionnaire Date: Name: Home Address: Phone Number: Date of Birth: email Address: Marital Status: What would you like to be called by the Doctor: Please list how you would like to be contacted for test results: In case of emergency, contact: Relationship: Emergency Contact Phone #: Please list your main reason for making an appointment: Please list other doctors who are also currently treating you: Please list your current medical problems: (list the conditions you are currently being treated for)

Past medical History: Please list all hospitalizations, major illnesses and surgeries: Allergies or Drug Reactions (list drug and reaction): Who lives with you in your home? (Spouse, children, in-laws, significant others, etc.) What is Your Occupation? What are your hobbies? Birthplace: Education: Do you get regular exercise: (describe): Do you wear seat belts? (Circle One) Always Usually Occasionally Never Smoking history: Check which one applies: [ ] Never Smoked [ ] Previous Smoker: Started at Age Stopped at Age On average, how many packs per day? [ ] Current smoker: Started (age) On avenge, how many packs per day?

Do you drink wine, beer, or other alcoholic beverages? [ ] No [ ] Yes If yes, how many times in the last year have you drank 4 or more drinks on one occasion? Have you ever had a drinking problem? [ ] No [ ] Yes How many cups of coffee or caffeinated drinks do you drink daily? Do you use marijuana, cocaine, any street drugs or prescription drugs not prescribed for you? [ ]Yes [ ] No (Leave blank if you would rather discuss with doctor.) Family History: Family Member Age if Living Age at Death Health Problems or Cause of Death Mother Father Siblings Children *Please include cancer, diabetes, heart attacks, high blood pressure, strokes, tuberculosis, and other important illnesses.

Name of Medication Prescribed By Dosage When is the Medication taken Mg/units/drops How many times a day? Mornings, afternoons? Medication ABC Dr. ABC 5 mg 2 times, morning & night Purpose Ulcer Refills Needed Yes Please list all the medications you are taking, including over-the-counter medications, vitamins, herbs, and other treatments. Include the name of the Doctor who prescribed the medications, and why you are taking the medications (e.g. for high blood pressure, arthritis, cholesterol, etc.) If you are not sure why you are taking the medication, write "don't know'', and ask your doctor to explain why and how to use the drug properly. Also ask about the drug's side effects and what to do if you experience a side effect. Remember to update your medicine list when your doctor stops, changes, or updates your medications. Please bring your medication list with you to Doctors' Visits, Emergency Room or Walk-In Clinic visits, Nursing Home visits, to your Home Health Providers, and to the Hospital. If you are unable to bring a medication list with you to your doctor's appointment, please bring your bottles.

Past medical history: Please check whether you have ever had the following: CONDITION YES NO CONDITION YES NO Hypertension Diabetes Cancer Heart Murmur Heart Problems Asthma Emphysema or COPD Positive skin test for TB Tuberculosis Blood clots Previous Herpes, Gonorrhea, Syphilis or Chlamydia Ulcers Colon polyps Gall Bladder problems Hepatitis or Jaundice Liver Problems Asbestos Exposure HIV Infection Pancreatitis Kidney Problems Abnormal Pap Smear in past High PSA (Men Only) Seizure Depression or Anxiety Stroke Blood Problems Thyroid Problems Arthritis Radiation Treatments To Head or Neck Other (List) VACCINATIONS YES/NO Date TESTS YES/NO Date Tetanus Influenza (Flu Shot) Pneumonia Hepatitis A Hepatitis B Shingles Other (List) Stool Cards for Colon Cancer Testing Colonoscopy Sigmoidoscopy Bone Density Mammograms Pap Smear (Women Only) PSA (Men Only) Eye Exam by Eye Doctor

Please check whether or not you currently have (or had them in the past 2 weeks) these conditions: CONDITION YES NO CONDITION YES NO Fatigue Fever or chills Recent weight change Headache Vision problems Double vision Blurred vision Eye itching Eye pain Hearing loss Ear ache Ringing in ears Runny nose Nosebleeds Nasal congestion Snoring Hoarseness Sore throat Mouth sores Breast lump or pain Chest pain Irregular Heart Beat Pounding heart beat Shortness of breath Cough Wheezing Decreased appetite Increased appetite Difficulty Swallowing Heartburn Nausea Vomiting Abdominal pain FOR WOMEN ONLY Pelvic Pain Abnormal Vaginal Bleeding Vaginal Discharge Sexual Difficulties Date of last menstrual period Black Tarry Stools Rectal Bleeding Diarrhea Constipation Blood in Urine Urinating too often Too much Urine Getting up at night to Urinate Pain with Urination Excessive Thirst Weakness Easy Bruising Muscle Aches Joint Pain Joint Stiffness Swelling in Arms or Legs Dizziness Fainting Memory Problems Numbness Anxiety Depression Trouble sleeping Hallucinations Stress Itching Dry skin Rash Lump or Spot on Skin FOR MEN ONLY Straining with Urination Pain or Lump on Testicle Discharge from Penis Prostrate Problems Difficulty with Erection Sexual Difficulties

Geriatric Intake--please complete if you are over 65 years old, or if you have concerns about the topics listed below. Do you have medical Durable Power of Attorney for Healthcare? [ ]No [ ] Yes (If yes, please bring a copy) Name & Relationship We want to know if you need help with any of the following and who helps you. Task Don t Need Need Who Helps Help Help Feeding Yourself Getting from bed to a chair Getting to the toilet Getting dressed Bathing Using the telephone Taking your medicines Preparing your meals Managing money/finances/checkbook Doing laundry Doing housework Shopping for groceries Driving Doing handyman work Climbing a flight of stairs Getting places beyond walking distance Are you afraid of falling? [ ] Yes [ ] No Have you had a fall in the past year? [ ] Yes [ ] No If yes, please tell us about your last fall: Date of the fall: How did this fall happen? Did you need to see a doctor or other professional for treatment after this fall: [ ]Yes [ ]No Do you use a walking aid such as a cane or walker? [ ]Yes [ ]No Do you drive? [ ]Yes [ ]No 6

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