New Patient Form Patient Name * First Name Last Name Date of Birth * MM DD YYYY Today's Date MM DD YYYY PERSONAL INFORMATION Home Address Address 1 Address 2 City State/Province Zip/Postal Code Country Cell Phone (###) ### #### Home Phone (###) ### #### Is it ok to leave a message? Yes No PCP: Date of Last Physical MM DD YYYY Emergency Contact Name Emergency Contact Phone (###) ### #### Relationship to patient? What is your reason for visiting the office today? * MEDICATION Do you have any allergies to medications? Yes No If yes, please list below Do you take medications regularly? Yes No If yes, please list below. Include medication name, dose/frequency/route, and any notes. PAST MEDICAL HISTORY Do you now or have you ever had: Asthma Diabetes High Blood Pressure High Cholesterol Hypothyroidism Depression or Anxiety Heart problems Crohn's or Ulcerative Colitis Diverticulitis Blood clot (DVT or PE) Anemia Substance Abuse/Addiction Stroke Epilepsy (Seizures) Kidney Disease Ulcer Hepatitis HIV/AIDS Cancer (provide details) Other Health Problems HEALTH SCREENING Date of last colonoscopy MM DD YYYY Date of last bone density screening MM DD YYYY Date of last cholesterol check MM DD YYYY Date of last mammogram MM DD YYYY Date of last dermatology visit MM DD YYYY Date of last dental visit MM DD YYYY SURGICAL HISTORY Have you had any surgeries? Yes No If yes, please list below with any details, including date, surgery type, and any notes/complications Other than surgeries, have you been hospitalized? If so, when and why? FAMILY HISTORY Please provide details for applicable fields, including family members (mother, father, paternal and maternal grandparents, and siblings) High Blood Pressure Diabetes Heart Disease Obesity Stroke Mental Health Issues Cancer (type & age at diagnosis) Anesthesia Problems Thyroid disorder Other PERSONAL AND SOCIAL HISTORY What is your highest education? High school College graduate Advanced degree What do you do for work? Marital status: Never married Married Divorced Separated Widowed Partnered Do you smoke? Yes No If yes, how much? Do you drink alcohol? Yes No If yes, how much? Do you use any other drugs, such as marijuana, cocaine or narcotics? Yes No Do you exercise? Yes No Do you wear your seatbelt? Yes No Do you have concerns for your safety? Yes No REPRODUCTIVE HISTORY Age of first period Date of last period MM DD YYYY Are your periods regular? Yes No How often do your periods come? How long do your periods last? Do you have problems with heavy periods? If yes, please explain. Do you have problems with severe cramping? If yes, please explain. Are you sexually active? Yes No Are your partner(s) Men Women Both Do you have pain with intercourse? Yes No Have you used birth control? Yes No If yes, please list what forms. Have you reached menopause? Yes No If yes, at what age? Do you take hormones? Yes No When was your last pap smear? MM DD YYYY Did you get the HPV vaccine (Gardasil)? Yes No Have you ever had an abnormal pap smear? Yes No If yes, please explain. Have you ever had genital herpes, chlamydia, syphilis, gonorrhea, or another sexually transmitted infection? Have you had any pregnancies? Yes No If yes, please list details below, including date, outcome (birth, abortion, miscarriage), and any notes (D&C, cesarean, weight). SYSTEMS REVIEW - In the past month, have you had any of the following problems? General Weight change Fatigue Night sweats Digestive Nausea/vomiting Abdominal pain Constipation Diarrhea Blood in stool Psychological Difficulty sleeping Excessive worries Lack of interest in activity Neurologic Headache Dizziness Memory loss Genitourinary Pain with urination Incontinence Blood in urine Frequent urge to go Heart/Lungs Chest pain Shortness of breath Palpitations Wheezing Muscles/Joints Joint pain Weakness Swelling of joint Swelling of legs Gynecologic Vaginal discharge/itching Pelvic pain Abnormal bleeding Heavy bleeding Pain with intercourse Decreased interest in sex Head/Neck Hearing difficulty Vision problems Hoarse voice Difficulty swallowing Skin Rash/redness New lesion Thank you!
