New Patient Information Form

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Transcription:

New Patient Information Form Patient Label Dear Patient: Please take a few minutes to complete this form. Your answers will help the doctors and staff plan and provide your care. If you are unsure of any answers, leave the area blank. We will review this form with you after you complete it. Thank you for your cooperation and assistance. Name: Date: Time: Temperature: Pulse: Resp: BP: HT: WT: Person Completing This Form: Patient Other (Relation to patient) Who referred you to see our doctors? Primary Care Physician: Primary Language: English Spanish Other Do you need a translator? Educational Background: Highest grade completed: College Post Graduate Do you have an Advance Directive? Yes Do you have a Power of Attorney? Yes Religion: Baptist Catholic Methodist Jewish Muslim Jehovah Witness Other Any problem with your vision? Yes Any problem with your hearing? Yes What is your medical reason for seeing the doctor? Please briefly tell us about your current problem (when it started; symptoms; treatment) How did you hear about our center? Referral from physician Family or friend TV ad Radio ad Billboard Internet Other Have you ever been treated for cancer? Yes Have you ever received radiation other than routine x-rays? Yes (When? Where? ) Have you ever had a blood transfusion? Yes (When? Where? ) Have you ever received chemotherapy? Yes (When? Where? )

Past Medical History: Please check all previous illnesses and list year of onset Year Description Year Description Heart Problems Cancer - Type: Heart Attack Skin Cancer High Blood Pressure Thyroid Problems Diabetes Stomach Problems (GERD, ulcers, other) Circulation Problems Liver Problems Stroke Pancreas Problems Asthma Hemorrhoids Emphysema/COPD Seizures Tuberculosis Migraine Headaches Breast Problems Cataracts Prostate Problems Blood Clots in Legs Kidney or Urine Problems HIV/ AIDS Urine leaks Ulcerative colitis, Cohn s disease, or other inflammatory bowel disease. Others: Surgical History: Please check all previous surgeries and list year of procedure Year Description Year Description Tonsils Removed Appendix Removed Esophagus/Hiatus Hernia Small Intestine Stomach Surgery Colon or Rectum Gallbladder Hemorrhoid removal Pancreas Hysterectomy Liver Heart Breast Prostate Cataracts Biopsy Other surgeries: Date Operation Doctor Hospital Vaccination History: Last Influenza Vaccine: Last Pneumonia Vaccine:

Last Colonoscopy: Last Mammogram: Last Pap Smear: Obstetric/Gynecologic History How many times have you been pregnant? How many babies have you had? How many miscarriages or terminations have you had? Age at 1 st birth: Was any pregnancy complicated? Yes If yes, describe: Menstrual Cycle: What age started? Date last cycle: Age at Menopause: Menopause Reason: Have had a hysterectomy? Yes If yes, why/when? If yes, were your ovaries also removed? Yes Have you ever breast fed? Yes If yes, number of times? Have you ever or are you now taking any hormone or birth control pills? Yes If yes, When? Name of hormone pill: : Reason for Stopping Hormone pills: Family History of Cancer Relative Cancer Type Age at Diagnosis Living? Y/N Father Mother Son(s)/Daughter(s) Other Relatives Mother Side Father Side Cause of death Age at death Social History With whom do you live? _ Are you: employed, retired, disabled, other: Describe your job or indicate your job title: Do you personally receive home health care? Yes If yes, which agency? Do you smoke? Yes If yes, how much and for how long? If you have quit, how long has it been? How much and for how long did you smoke before you quit? Do you use smokeless tobacco? Yes How much and for how long? Do you use illegal drugs? Yes What and for how long? Do you drink alcohol? Yes How much and for how long? If you have quit, how long has it been? Describe your daily activities:

Review of Systems: Check all problems that you are having now General: To Be Completed By Medical Team Fever chills Sweats Change in sleep habits Weight Changes Fatigue Psychological: Anxious Other Depressed Neurological: Memory changes Dizziness/fainting Blurred vision Head and Neck: se bleeds Problems swallowing Lesions in mouth or throat Cardiovascular: Leg pain/ swelling Fast heart beat Respiratory: Wheezing Short Breath Breast: Lumps Changes Gastrointestinal: Constipation Blood in stools Indigestion Nausea/vomiting Yellow skin or eyes Genitourinary: Burning Blood in urine Unable to control bladder Musculoskeletal: Swelling Stiffness Skin: Open Sore Abnormal color Change in moles Endocrine: Swelling Hematology: Abnormal bleeding Easy bruising Numbness/ tingling Headache Seizures Hoarseness Sore throat Chest pain Cough Bloody phlegm Nipple discharge Change appetite/ diet Cramping Diarrhea Black stools Frequency Dribbling Joint/ back pain Trauma/ falls Rashes Joint/ back pain Swelling/groin/armpit/neck Prior transfusion

Is there anything else you would like us to know about yourself or your visit with us today? Patient Signature: or Guardian / Surrogate Signature: (If you have medical POA, please provide a copy) Signature Signature Printed Name Printed Name Date Date Revised: 11/4/2013 Reviewed: 11/4/2013

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