Patient Information
* Required
* Name:
* Address:
* City:
* State:* Zip Code:
* Home Phone:
Work Phone:
Cell Phone:
* Date of Birth:
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January
February
March
April
May
June
July
August
September
October
November
December
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2010
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1920
Social Security Number:
Marital Status:
- select -
Single
Married
Divorced
Separated
Other Partner
Name of Nearest Relative:Incl. Spouse, Sig. Other
Relationship:
Insurance Information
Insurance Plan:
Insurance Number:
Insurance Group:
Co-Pay Amount:(provide prior to visit)
$
Employment Information
Place of Employment:
Occupation:
Employers Workers Compensation Carrier (if applicable):
Referral Information
Previous Physician:
Date Last Seen:
Referred To This Office by:(Relative, Friend)
Reason For Visit
State the reason(s) that you are here to see the doctor (eg. new patient exam, yearly, specific problem(s) to be addressed). Please try to describe what the problem(s) is/are, when the problem(s) began, how severe the problem(s) is/are, and all related symptoms that you may be having. Please state whether these are ongoing or new problems.
Medication Information
Current Medications
Allergies to Medication:(Codiene, Penicillin, etc)
Health-Food or Over-the-Counter ProductsPlease list any health-food or over-the-counter products you are taking, or have taken recently (eg. Kava, DHEA, supplements, cough medicines, St. John's Wart, etc.)
Medical History
List any Significant Illnesses or Injuries in the Past Five Years
List any Surgeries in the Past Five Years
List any Hospitalizations in the Past Five Years
Have you been, or are you now under the care of a Specialist(s)? If so, please provide name(s).(Including Orthopedic, Neurologist, Psychiatric, Chiropractic, Physical Therapy)
Will you require referrals in the near future? If so, please list.
Social History
Smoking History
Packs Per Day:
Select
Not-Applicable
1/2
1
2
3
Number of Years:
Have You Quit?:
Select
Yes
No
If Yes, what date:
Are you interested in quitting?:
Select
Yes
No
Alcohol History
Alcohol Usage:
Select
None
Rarely (Socially)
Minimal (1-2 weekly)
Moderate (3-5 weekly)
Heavy (5+ per week)
Type of Liquor:Beer, Wine, Vodka, Whiskey, etc.
Other Lifestyle Information
Caffeine Intake:Including Soda, Tea
Select
Minimal (1-2 cups/day)
Moderate (3-5 cups/day)
Heavy (5+ cups/day)
Illicit Drug or Stimulant Use in the Past Five Years:
Diet:
Select
Healthy
Normal
Poor
Fear of Foods
Please Explain:
History of eating disorder:(eg Anorexia or Bulemia)
Select
Yes
No
Please Explain:
Amount of Exercise:
Select
1 day/week
2 days/week
3 days/week
4 days/week
5 days/week
6 days/week
7 days/week
Type of Exercise:(Walking, Aerobics)
Do you wear seatbelts?:
Select
No
25% of the time
50% of the time
75% of the time
100% of the time
Do you use sunscreen?:
Select
Yes
No
Sexual History
Do you have a history, or have you been in contact with, someone having any the following?: Please Explain your illness and treatment:
Do you have, or have you had, more than 3 sexual partners?
Select
Yes
No
Family Health History
Significant Family Illnesses List any family history of cancer, diabetes, high blood pressure, heart disease, stroke, alcoholism, bleeding disorder, liver disease, kidney disease, other illness or disease.
Family Psychological History Is there any family history of bipolar disorder, manic depression, schizophrenia, severe depression, chronic anxious state, or chronic treatment with anti-depressant, anti-anxiety or other medication?
Your Medical History
Symtoms or Illnesses over the past 1-2 years
For Women Only
Who is your Obstetrician-Gynecologist:Including Nurse Practitioner or mid-wife
Date of last pelvic exam/pap smear:
Date of last mammogram:
List abnormal pap smears:
List abnormal mammograms:
List treatments for above:
Monthy Breast Exam?
Select
Yes
No
Number of times pregnant:
Number of Children
Ages of Children
Pregnancy Terminations
Reason for Terminations
Hormonal History Are you taking estrogens, estrogen/progesterone combination, Evista, Miacalcin, patch or other medication? If so, please list:
Menstrual History
Last Mentrual Period
Type of Birth Control
Select
None
Natural
Condom
IUD
Foams
Birth Control Pill
Name of Pill (if applicable)
Menstrual Periods
Select
Regular
Irregular
Days in cycle
Length of menses
Age at onset of menses
Any irregular bleeding, spotting, pain etc.?
Premenstrual Symptoms
Postmenopausal?
Select
Yes
No
If No, months since last menstrual period:
Surgical History eg Hysterectomy (removal of uterus only); Ovaries only removed; Total Hysterectomy (Uterus + Ovaries), or Tubal litigation ("tubes tied")
Age at time of surgery
Reason for surgery
Other Surgeries
Urinary symptoms, lack of control, incontinence, inability to urinate, etc?
Questions or Problems
Do you have any question or problems that you would like the doctor to focus on during your visit?
