A. Please include any medications (herbal, prescription, or Over-the-counter) and any supplements that you are currently taking.

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Transcription:

New Patient Questionnaire Please complete this and bring it with you to your visit. If you have it completed five days or more prior to your visit, please mail or fax it to our office. Most recent treating primary care doctor and date of last visit Ongoing specialty care HISTORY OF PRESENT HEALTH OR ILLNESS: What goals do you have for your doctorʼs visit today? PAST MEDICAL HISTORY ITEMS A. Please include any medications (herbal, prescription, or Over-the-counter) and any supplements that you are currently taking. Medication Strength of dose Times taken per day Date started medication B. Please include any medications (herbal, prescription, or Over-the-counter) that you may have tried in the past and then stopped. Please comment on why you stopped the medication.

Medication Stop date Reason stopped C. Please indicate any allergies you may have, whether they are to medications or to things in the environment. Medication or Allergen Reaction D. Please list any medical problems you have, and other details as able. Medical problem Controlled or uncontrolled Present concerns or details E. Please list any surgeries you may have had, along with the dates as best as you can remember. Surgery Complications, if any Date of Surgery (mm/yy) Location of care

F. Recommended vaccines vary with age group and exposures. Not all vaccines are indicated in all persons. Please list your most recent dose of the following vaccines, if known. Vaccine Date Any reaction Tetanus toxoid (Td) TdAP Pnemonia (Pneumovax) Flu Pertussis Hepatitis A Hepatitis B Yellow Fever Chicken pox (varicella) Shingles vaccine MMR G. Do you know if you have had any of the following tests? Only some of tests are indicated, and tend to vary with age groups. Please identify which tests you may have had in the past. EKG Chest Xray Breathing test Test performed Date Location & outcome Exercise stress test Blood sugar test Liver function test Complete blood count Thyroid function check Colonoscopy Flexible sigmoidoscopy Stool check for occult blood Prostate Specific Antigen (PSA) (Men) Prostate exam (Men) Testicle exam (Men)

Test performed Date Location & outcome Clinical breast exam (Women) Mammogram (Women) Pelvic exam (Women) Pap smear (Women) Bone density scan (DEXA) SOCIAL HISTORY 1. Do you exercise? If so, what exercises and how many times per week? 2. Do you feel you are at your appropriate weight? If not, are you now doing anything to lessen your weight? Have you had success losing any weight in the past? If so, what strategy did you use? Do you eat five servings of fresh fruits or vegetables a day? Yes No 3. Do you use tobacco now? How much per day? If you used tobacco in the past, describe your usage. 4. Do you drink alcohol now? What type of liquor and how many per day? 5. Are you presently taking care of any young children, either as a parent, grandparent, or as a job? If so, please describe Are you presently taking care of older persons with immunity problems? If so, please describe 6. Do you have any pets in the house? 7. Have you traveled outside the country in the last year? 8. Are you a blood donor? Yes No Double Red Donor? Yes No If not, would you consider becoming a donor? Yes No Family History Brothers Sisters Mother Father Kids Diabetes High blood pressure Went on kidney dialysis Heart disease before 55 in men Heart disease before 65 in women Breast cancer Ovarian cancer Colon cancer or colon polyps

Melanoma (deadly skin cancer) Prostate cancer Genetic illnesses Bipolar Hemochromatosis Thyroid illness Other REVIEW OF SYSTEMS Please circle any symptoms you are experiencing. CONSTITUTIONAL Weight loss no yes Weight gain no yes Fever no yes Chills no yes EYES: Itching no yes Eye dryness no yes Changing vision no yes EARS, NOSE, MOUTH, THROAT: Hearing loss no yes Ringing of ears no yes Nose bleeds no yes Frequent congestion no yes Frequent sore throats no yes Hoarseness no yes CARDIOVASCULAR: Chest pain no yes Lower extremity swell no Awake short of breath no PULMONARY: yes yes Chronic cough no yes Cough up blood no yes Short of breath no yes Wheezing no yes Abnormal chest x-ray no yes Positive PPD no yes GASTROINTESTINAL: Loss of appetite no yes Difficulty swallowing no yes Painful swallowing no yes Nausea or vomiting no yes Pain in abdomen no yes Heartburn no yes Colon polyps no yes Blood per rectum no yes Constipation no yes Diarrhea no yes Black (tarry) stools no yes GENITOURINARY: Blood or pus in urine no yes Getting up nights to urinate ( times) no yes Trouble starting urine no yes Incontinence no yes Incomplete voiding no yes Penis discharge (men) no yes Erectile dysfunction (men) no yes Irregular menses (women) no yes Vaginal discharge (women) no yes MUSCULOSKELETAL: Joint pain no yes Red, hot joints no yes Injury no yes SKIN: Changing moles no yes Rash no yes Hair changes no yes Rash to lips, mucosa no yes Dry skin no yes Breast changes no yes NEUROLOGIC: Weakness no yes Tingling no yes Numbness no yes Fatigue no yes Insomnia no yes Headache no yes Tremor no yes Forgetfulness no yes PSYCHIATRIC: Inability to enjoy no yes Sadness no yes Thoughts of self harm no yes Thoughs of harm to others no yes ENDOCRINE: Excessive urine no yes Excessive thirst no yes Hair growth no yes Heat or cold intolerance no yes Growing hands/feet no yes HEMATOLOGIC: Low blood counts no yes Armpit, neck or groin swelling no yes ALLERGIC: Hay fever no yes Frequent infections no yes

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