Scttsdale Family Health New Patient Frm Patient Name: Date f Birth: Tday s Date PHARMACY: (Please list name and number f pharmacy yu wish t have prescriptins sent t.) Pharmacy Pharmacy Number MEDICAL HISTORY : (Check any cnditin yu have r have had in the past.) Abnrmal Heart Rhythm (tachycardia, atrial fibrillatin, flutter, etc) Allergies Anxiety Asthma Arthritis Back Pain Cancer If yes, list what kind(s) Chlesterl Disrder Depressin Diabetes Fainting/Dizzy Spells Fatigue Gastritis/Stmach Ulcer/Stmach Prblems Headaches Bld Pressure Prblem If yes, circle if High r Lw Kidney Failure Lung Disease Liver Disease Pleurisy Psychiatric Illness If yes, please describe Rheumatic Fever Gastrintestinal (GI) Disrder If yes, please describe Strkes r Transient Ischemic Attacks (TIA) Thyrid Disease Tuberculsis Visin Disrder Weight Fluctuatins Please list any ther medical prblems yu may have that was nt listed abve: 1 f 6
Scttsdale Family Health New Patient Frm Have yu ever had any f the fllwing: Alchlism Drug Dependency Transfusins Have yu had any f the fllwing: Sexually Transmitted Diseases (STD) and ther infectin (check any that apply): Gnrrhea HIV/AIDS Genital Warts Abnrmal PAP Smear Chlamydia Genital Herpes Trichmnas SURGICAL HISTORY List any surgeries yu have had and the apprximate date (e.g. hernia, appendectmy, gallbladder, wisdm tth extractins, C Sectin, etc) Surgery Apprximate Date r Number f Years Ag OTHER PROVIDERS : Please List Other Dctrs/Prviders Yu See. Dctr/Prvider Name Specialties 2 f 6
CURRENT MEDICATIONS Scttsdale Family Health New Patient Frm Please list the name, dsage, and hw ften taken. Include inhalers and nasal sprays, etc. [OK TO ATTACH LIST] Medicatin Name Dsage Times per day List any medicatins that were recently stpped and reasn why the medicine was stpped: DIETARY SUPPLEMENTS, HERBS, VITAMINS: Please list name, dsage, and hw ften taken. [OK TO ATTACH LIST] Name Dsage Times per day ALLERGIES: List any medicatins r fd that has caused a bad reactin r allergy in the past. Medicatin/Fd What happened with expsure 3 f 6
FAMILY HISTORY Scttsdale Family Health New Patient Frm Please list any medical cnditins that run in the family (e.g. thyrid disease, diabetes, high bld pressure, alchlism, depressin, cancer, etc) Family Member Mther Father Sibling(s) Medical Cnditins Children Other family members: SOCIAL HISTORY: 1) What is yur current prfessin? 2) Have yu ever held an ccupatin that put yu at risk fr any medical prblems: r N If yes, please describe: 3) Are yu currently married? YES NO 4) D yu have any children? YES NO If yes, please state their names and ages: 5) Have yu ever smked? If, a) D yu still smke? YES NO b) Fr hw many years did/d yu smke? c) On average, hw many cigarettes d yu smke per day? 6) Have yu used any ther tbacc prducts? If yes, what types 7) D yu exercise? YES NO If yes, what type r frm f exercise If yes, hw many days a week and hurs per day 8) D yu cnsume alchl? If yes, hw many drinks? per day/week/mnth (circle apprpriate) If yes, what type? 9) D yu feel that yu have any risk factrs fr Sexually Transmitted Disease (multiple partners, unprtected intercurse, cheating partner, etc) : YES NO 4 f 6
Scttsdale Family Health New Patient Frm Current activity level (check which describes mst accurately): Nt much (sedentary) Minimal Active, but N Exercise Sme Exercise Regular Exercise : Please describe yur current diet (check all that apply): Well balanced, cntrlled prtins Unbalanced Excessive Prtins Lw Salt Lw Fat Lw Carbs Restricted calries ( cal/day) Other: End f Life Planning D yu have a written advance directive, living will, pwer f attrney, r end f life planning (such as resuscitatin desire)? N If yes, is this in yur chart? D yu wish t discuss any end f life issues with yur dctr? In the last 2 weeks have yu felt depressed? Have yu drpped any f yur hbbies/interests? D yu prefer t stay at hme rather than ging ut? Are yu having significant truble with yur memry? D yu feel sad mst f the time? D yu feel yu have any significant memry prblems? Have yu frgtten what yu had fr dinner yesterday? D yu have t keep lists s yu dn t frget things? D yu frequently lse things at hme r at wrk? Have yu ever gtten lst while driving? Have yu ever frgtten why yu are at a stre r ther place? Have yu had truble balancing yur checkbk lately? D peple ften accuse yu f repeating yurself? D yu feel yu have any significant safety cncerns? D yu have any truble seeing? D yu have any truble speaking? D yu have any truble hearing? D yu have any truble bathing? D yu have any truble dressing? D yu have any truble eating? 5 f 6 N Unsure N N N N
D yu feel unstable r unsteady when standing? Scttsdale Family Health New Patient Frm D yu have any truble using stairs, if yu have them? Have yu fallen r almst fallen in the last 60 days? D yu knw f any fire hazards in yur hme? Wuld yu have any truble getting 911 help if needed? ETHNICITY: N Caucasian African American Native American Asian Hispanic Middle Eastern Multi ethnic Other HEALTHCARE MAINTENANCE: 1) When was yur last physical exam? 2) When was the last time yu had screening labs? 3) When was yur last tetanus immunizatin? 4) Have yu had the pneumnia vaccine? YES, when NO 5) Have yu had the influenza vaccine? YES, when NO 6) Have yu had a shingles vaccine? YES, when NO 7) Have yu had a screening clnscpy? YES, when NO 8) When was yur last EKG? 9) Have yu had a cardiac stress test? YES, when NO 10) When was yur last eye exam? FOR FEMALE PATIENTS ONLY: 1) Are yu pregnant? YES, hw many weeks/mnths NO 2) Hw many times have yu been pregnant? 3) Hw many live births? 4) Date f last mammgram 5) Date f yur last perid 6) Date f last PAP Smear 7) Last bne scan FOR MALE PATIENTS ONLY: 1) Date f last Rectal/Prstate Exam 2) Last PSA lab 6 f 6