NEW PATIENT QUESTIONNAIRE

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Transcription:

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, for what condition Referring Physician Please list the 2 main health issues you would like to address during your visit today: 1) 2) If you were not referred by another physician, how did you find out about us? Website Social Media Phone Book Billboard Newspaper Name of friend/relative PLEASE LIST ALL PRESCRIPTION MEDICATIONS & CONTRACEPTIVESTHAT YOU ARE CURRENTLY TAKING Name Dosage Times/day Treatment for what condition 1 st prescribed PLEASE LIST ALL OVER THE COUNTER MEDICATIONS THAT YOU ARE CURRENTLY TAKING Including vitamins and herbal medications Name Dosage Times/day Treatment for what condition 1 st prescribed PHYSICIAN NOTES SECTION - HPI

ALLERGIES Please list any medications or products you have taken which cause a true allergic reaction (hives, itching, rash, or difficulty breathing): INDICATE ANY OF THE FOLLOWING ILLNESSES YOU NOW HAVE OR HAVE HAD IN THE PAST CONDITION YEAR TESTS PERFORMED TREATMENT RECEIVED High blood pressure Heart disease High cholesterol Stroke Diabetes mellitus Seizures Glaucoma Osteoarthritis Thyroid Osteoporosis Cancer (if yes, what type) Stomach ulcers/reflux disease Uterine fibroids Urinary incontinence Depression Panic disorder Eating disorder Breast biopsies Abnormal pap smear Other SURGERY YEAR Date of last menstrual cycle / / Number of pregnancies? Number of live births? Method of birth control Father s History OB/GYN HISTORY Was your uterus removed? Yes No Why? Have your ovaries been removed? Yes If yes, why? FAMILY HISTORY List all major illnesses including cancers, heart conditions, diabetes, high blood pressure, high cholesterol, depression, osteoporosis, kidney disease. Is your Father? Alive Age Deceased Age What types of health problems if any did he have? Mother s History Is your Mother? Alive Age Deceased Age What types of health problems if any did she have? Do you have any brothers or sisters? What types of health problems do/did they have? Do your children have any health issues? What types of health problems do/did they have? No

SOCIAL HISTORY Current employment status: Disabled Part time Full time Retired Self-employed Other What type of occupation do you (or did) you have? Current marital status? Single Married Separated Divorced Widowed Other HABITS Have you ever smoked cigarettes regularly? Yes No If yes, how many packs per day? (avg) How many years? Are you still smoking? Yes No If no, when did you stop? Do you drink alcoholic beverages? Yes No How many beers day/week? How many mixed drinks or glasses of wine daily? Do you have any drug, nicotine or alcohol habits which concern you? Yes No Do you exercise? Yes No Type Days per week exercise performed Minutes per session LIST A DAY OF YOUR USUAL DIET Breakfast Lunch Dinner Snacks (what hour) SEXUAL HEALTH Are you sexually active? Yes No If yes, are you satisfied with your current sexual experiences? Yes No If no, what portion are you not satisfied with? Sex drive Orgasm Arousal Lubrication Do you experience pain with intercourse? Yes No Does your partner have any sexual difficulties? Yes No Other? Sexual health scale (0 not good 10 excellent) 0 1 2 3 4 5 6 7 8 9 10 MENTAL AND EMOTIONAL HEALTH Do you feel emotionally balanced? Yes No What are your primary sources of stress? Who is your biggest support group in times of stress? Immediate family Friends Spouse Emotional health scale (0 not good 10 excellent) 0 1 2 3 4 5 6 7 8 9 10 SOCIAL HEALTH Do you have questions or concerns about Advanced Directives or a Living Will? Yes No If yes, please describe: Please list which documents you currently have:

When was your last mammogram Was a breast procedure performed When was your last pap smear Was a biopsy or other procedure was performed: When was your last bone densitometry What was the result When was your last colonoscopy Were colon polyps ever found HEALTH MAINTENANCE Performing doctor IMMUNIZATIONS TYPE YEAR TYPE YEAR Tetanus booster Tetanus, diphtheria Tetanus, diphtheria, (Tdap) Pneumonia vaccine Flu vaccine Hepatitis B HPV vaccine Shingles vaccine Eye exam Do you wear a seat belt? Yes No Sometimes REVIEW OF SYSTEMS Please check any of the following symptoms or problems you are currently experience on a regular basis. If the problem has been resolved, leave it blank. If you are unsure, place a question mark (?) by the medical issue. General Nose/Throat Skin Changes in weight Fatigue Trouble getting to sleep Trouble staying asleep Any issues affecting quality of sleep Eyes Changes in vision Earaches Hearing problems Frequent sinus problems Respiratory Wheezing Shortness of breath Rash Excess facial hair/body hair Changes in moles Hematological Frequent bruising Bleed easily Cardiovascular Chest pain or pressure Swelling of legs Rapid heartbeat Neurological Dizziness or trouble walking Numbness Memory problems Frequent or severe headaches Breast New or unusual lumps Nipple discharge Musculoskeletal Muscle weakness Muscle or joint pain Joint swelling Psychiatric Depression Anxiety Urogenital Incontinence Vaginal Dryness Pelvic Pain Gastrointestinal Frequent diarrhea Nausea/Vomiting Constipation Heartburn Endocrine Hair loss Excessive thirst Cold intolerance Hot flashes We appreciate your cooperation in completing this form for your physician.

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