COMPREHENSIVE NEW PATIENT QUESTIONNAIRE

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Transcription:

What brings you in today? What do you prefer to be called (nickname)? Please list all of your medical conditions. 1. 5. 2. 6. 3. 7. 4. 8. What surgical or medical procedures have you had in the past? 1. 4. 2. 5. 3. 6. Please tell us about medical conditions in your family including cancer, diabetes, heart disease, etc., and at what age they developed the disease: Mother: Age: Father: Age: Siblings: Age: Others: Age: What medications, herbs, and vitamins/ supplements are you currently taking? Remember to include over-the-counter medicines. Please include the doses and how often you take each one. 1. 6. 2. 7. 3. 8. 4. 9. 5. 10. Allergies? Yes No If yes, reactions? Social History: Relationship status: Married/Partner Single Divorced Widowed Preferred sexual partner: Men Women Both Never sexually active Currently sexually active: Yes No Have you ever been pregnant: Yes No How many times? Do you have children? Yes No How many? UCLA Form #520200 Rev. (7/15) Page 1 of 5

Who lives with you at home? Do you feel safe at home and in your current relationship? Yes No What is your occupation? What (if any) physical activity/exercise do you engage in and how often? How would you describe your dietary intake? How much alcohol do you drink? per day per week If yes, how many times in the past month have you had more than 4 alcoholic drinks in one day? Do you smoke? Now Past Never If so, how many per day and for how long? Have you ever had a blood transfusion? Yes No How often have you noticed the following emotions over the last two weeks: (check the answer that best describes how you feel) Little interest in None Several doing things days More than half the days Nearly every day Feeling down or None Several depressed days More than half the days Nearly every day Review of Systems: Please check if you are currently having any of the following symptoms. Constitutional Fever Night sweats Weight loss Fatigue Excessive sleepiness/ Insomnia Eyes Blurred vision Double vision Eye pain Eye dryness Respiratory Cough Trouble breathing Frequent Illness Gastrointestinal Nausea/vomiting Diarrhea Constipation Abdominal pain Heartburn Skin Rash Nail changes Mole Changes Endocrinologic Excessive thirst Hot or cold always Excessive urination Hematologic Abnormal bleeding/bruising Lumps or swelling UCLA Form #520200 Rev. (7/15) Page 2 of 5

Ear/nose/throat Hearing loss Ringing in ears Hoarseness Trouble swallowing Sneezing frequently Runny/Stuffy nose Snoring Choking/gasping during sleep Cardiovascular Chest pain Palpitations Genitourinary Leaking urine Trouble urinating Blood in urine Heavy vaginal bleeding Musculoskeletal Muscle pain or joint pain Muscle twitching/cramping Joint pain/stiffness Joint swelling Trouble walking Falls/fear of falling Back pain Psychiatric Anxiety Sad or depressed Trouble sleeping Memory problems Overwhelming Panic attacks Neurologic Numbness/tingling Tremors Headaches Dizziness Memory loss Health Maintenance/Prevention Please specify if and when you received the following services. All patients: Influenza (flu) vaccine HIV test Tetanus vaccine Last dental exam Pertussis vaccine Last eye exam Hepatitis A vaccine Hepatitis B vaccine Varicella vaccine Over 50: Pneumonia vaccine Blood in stool cards Zostavax vaccine Colonoscopy Pertussis vaccine Bone density scan Women only: All: Pap smear Under 27: HPV/Gardasil vaccine Chlamydia (urine) test Over 40: UCLA Form #520200 Rev. (7/15) Page 3 of 5

Mammogram Men only: Under 27: HPV/Gardasil Vaccine Over 40: Abdominal ultrasound PSA test Do you currently see any other physicians? Are you up to date on: Tdap (tetanus, pertussis/whooping cough) HPV (Gardasil) Influenza (flu shot) Pneumonia 23 Pneumonia 13 Shingles (Zostavax) Are you up to date on the following: Colonoscopy (colon cancer screening) Bone Density (osteoporosis screen) Mammogram (breast cancer screen) Pap smear (cervical cancer screen) Prostate cancer screen UCLA Form #520200 Rev. (7/15) Page 4 of 5

The information provided in this questionnaire is true and complete to the best of my knowledge. I understand that the accuracy of the information I have provided is important to my physician and my healthcare team in order to develop an individualized care plan for me. Patient or Representative Signature Date Time Print Name Relationship to Patient Interpreter (if applicable) Interpreter ID # Date Time Physician Signature Date Time UCLA Form #520200 Rev. (7/15) Page 5 of 5

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