Patient s Name (First, Middle, Last): Address: City: State: Zip Code: Email: Main Contact#: Alternate#: Work#: Date of Birth: / / Sex: Male Female SS# (optional): Marital Status : Single Married Divorced Widowed Occupation: Patient Referred By: Spouse s Name: Spouse s Date of Birth: / / Main Contact#: Alternate#: Emergency Contact: Relationship: Phone#: Primary Care Physician: Referring Physician: Phone#: Phone#: Insurance Information Primary Insurance: Policy/ID# Name of Policy Holder: DOB: / / Group/Acct #: Employer: Employer Address: City: State: Zip Code: Work #: Secondary Insurance: Policy/ID#: Name of Policy Holder: DOB: / / Group/Acct #: Employer: Employer Address: City: State: Zip Code: Work #: Complete Only if Patient is a Minor Father s/guardian Name: Mother s/guardian Name: Relationship: Relationship: Siblings: DOB: / / Other Siblings: DOB: / / Form.NewPatientHstory_PrecisionEndoRev006 Page of 5
NEW PATIENT MEDICAL HISTORY FORM DATE : NAME: D.O.B. / / OCCUPATION: LAST FIRST MI REASON FOR VISIT TODAY: REFERRING PHYSICIAN: Daytime Phone #: Alternate Phone #: Email address (optional): Can we contact you at this address for medical issues? Ethnicity: Hispanic n Hispanic Race: Caucasian Black Native American Asian Indian Other ALLERGIES (Include medications, foods, x-ray dyes) or circle NONE KNOWN Name of allergen Type of reaction Approximate date 4 5 CURRENT MEDICATIONS Include prescription, over the counter, and herbal medications. Attach extra sheet if necessary) or circle NONE if you are not taking any medication Name of medication Dose (mg) How often taken Reason for taking medication Physician prescribing 4 5 Form.NewPatientHstory_PrecisionEndoRev006 Page of 5
6 7 8 9 0 PHARMACY (List preferred Pharmacy or list pharmacy most frequently used for prescriptions) Name: Phone #: Fax #: Address: City: State/Zip: PREVIOUS HOSPITALIZATIONS (Include all non surgical hospitalizations. Attach extra sheet if necessary) or circle NONE Reasons for hospital stay Date (approximate) Hospital or city if known MEDICAL HISTORY. 4. 7.. 5. 8.. 6. 9. DRUG ALLERGIES.. 5.. 4. 6. HOSPITALIZATIONS Hospital Name Reason for Hospitalization Date/Year SURGERIES (Include all surgery in your lifetime. Attach extra sheet if necessary) or circle NONE if no surgeries Type of surgery Hospital or city if known Date/Year Form.NewPatientHstory_PrecisionEndoRev006 Page of 5
OB/GYN HISTORY: of Pregnancies : Last Menstrual Period : SOCIAL HISTORY Martial Status: Married Single Divorced Widowed Do you smoke? Quit If yes: How many cigs a day? for how long? If quit: when did you quit? When you did smoke, how many cigs a day? Do you exercise? for how long? Times per week?: Do you drink alcohol? drinks per Day Week Month Do you consume caffeine?, drinks per Day Week Month Do you currently use recreational drugs? Have you used recreational drugs in the past? FAMILY HISTORY - are you Adopted? Has any of your family members had any of the following? Mother Father Sister Brother Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Age Diabetes Hypertension Ot High Cholesterol i Cancer Heart Disease Thyroid Disease Form.NewPatientHstory_PrecisionEndoRev006 Page 4 of 5
NEW PATIENT MEDICAL HISTORY FORM ODAY: NAME: D.O.B. / / LAST FIRST M.I. Please check X the complaint(s) or ailment(s) that apply to you. If you are unsure, place a question mark (?) General Fatigue / Tired Fever / Chills Males Only Blood in Urine Difficulty Achieving Erection Headache Foul Odor in Urine Weight Loss Pain in Testicles Weight Gain Trouble Urinating Eyes Difficulty Seeing Head Ears Dry Mouth Hearing Problems se Hoarseness Throat Lumps/Swelling in Neck Sore Throat Trouble Swallowing Cardiac (Heart) Chest Pain Irregular Heart Beat Pain with Walking Shortness of Breath Neuro Dizziness Fainting Headache Memory Loss Numbness Weakness Females Only Breast Discomfort Irregular Bleeding Last Menstrual Cycle Date... Painful Intercourse Post Menopausal Bleeding Trouble Urinating Vaginal Discharge Musculoskeletal Back Pain Joint Pain Muscle Pain Swelling Swelling in Feet/Ankles Skin Bruising Hair Hair Loss Nails Nail Problems Rash Skin Changes Respiratory Cough Shortness of Breath Use of Inhalers Wheezing Gastro- Intestinal Abdominal Pain Blood in Stool Change in Bowel Habits Constipation Heartburn Loss of Appetite Nausea Vomiting Mental Health Anxiety Depression Difficulty Sleeping/Concentrating History of Physical/Mental Abuse Mood Swings Stress Suicidal Recent Tests/ (Give month/year of last exam in right column. Health Maintenance Check left column if date is estimated.) Bone Density: Diabetic Foot Exam: Eye Exam: Mammogram: Physical: PSA: Tetanus Shot: F0.form.NewPatient_PrecisionEndoRev_006 Page 5 of 5