New Patient Medical History

Patient Name:

Today's Date:

Date

Address:

Home Phone:

Work Phone:

Cell Phone:

Employer:

Job:

Age:

Date of Birth:

Date

Emergency Contact (Name/Phone):

Please list all present problems and concerns:

1.

2.

3.

4.

5.

Please list all medications taken regularly, dosage and length of time each has been used. Include over-the-counter medications, vitamins, aspirin, birth control pills, antacids, nasal sprays, eye drops, injections and skin preparations, herbal remedies. Length Taken Dosage Medication

1. Medication

Dosage

Length Taken

2. Medication

Dosage

Length Taken

3. Medication

Dosage

Length Taken

4. Medication

Dosage

Length Taken

5. Medication

Dosage

Length Taken

6. Medication

Dosage

Length Taken

7. Medication

Dosage

Length Taken

8. Medication

Dosage

Length Taken

Please list other physicians you see regularly:

Year

Reason or Problem

Year

Reason or Problem

Year

Reason or Problem

Year

Reason or Problem

Year

Reason or Problem

Year

Reason or Problem

Year

Reason or Problem

Year

Reason or Problem

Year

Reason or Problem

Year

Outcome/Name

Year

Outcome/Name

Year

Outcome/Name

Year

Reason or Problem

Name of Drug

Reaction

Name of Drug

Reaction

Name of Drug

Reaction

Name of Drug

Reaction

Have you had any of the following?

Tetanus and diphtheria:

Shingles:

Pneumonia:

Flu:

Hepatitis A:

Hepatitis B:

Is your father living?

Father's Age Now or At Death

Father's Medical Problems or Cause of Death

Is your mother living?

Mother's Age Now or At Death

Mother's Medical Problems or Cause of Death

Is your sister(s) living?

Sister(s) Age Now or At Death

Sister(s) Medical Problems or Cause of Death

Is your brother(s) living?

Brother(s) Age Now or At Death

Brother(s) Medical Problems or Cause of Death

Is your daughter(s) living?

Daughter(s) Age Now or At Death

Daughter(s) Medical Problems or Cause of Death

Is your son(s) living?

Son(s) Age Now or At Death

Son(s) Medical Problems or Cause of Death

Other Relatives:

Is there a family history of:

Have you ever smoked?

Do you smoke now?

How many cigarettes per day?

How many cigars per day?

Total years smoked in life?

If you quit, what year?

Do you chew tobacco or use snuff?

How many times per week?

Do you consume alcohol?

Ounces of liquor per week/day:

Glasses of wine per week/day:

Bottles of beer per week/day:

Is your alcohol use a problem for family, friends or on the job?

If you quit, what year?

Have you ever been counseled for alcohol or drug abuse?

Do you or have you in the past regularly used marijuana, cocaine, amphetamines or other mind altering drugs?

Do you drink coffee?

How many cups per day?

Do you drink other caffeinated drinks (cola, tea etc.)?

Do you exercise regulary?

If yes, describe:

How many hours do you sleep at night?

Do you snore?

Do you feel refreshed when you awaken in the morning?

What is your adult normal weight range?

Do you limit fat and cholesterol content of foods eaten?

Do you wear seatbelts?

Do you have smoke alarms in the home?

Do you have a carbon monoxide detector?

If you have guns in the home, are they kept locked up?

Do you wear ear protection around loud noise?

1

What years?

2

What years?

Did someone refer you to our practice?

If so, whom?

Is there anything else you would like us to know?

NEW PATIENT MEDICAL HISTORY

Hospitalizations/Surgeries

Broken Bones

Serious Illnesses

Blood Transfusions

Pregnancy History

Auto Accidents/Other

Drug Allergies or Reactions:

Vaccinations

Family Medical History:

Tobacco:

Alcohol and Drugs:

Caffeine:

Exercise:

Sleep:

Weight:

Diet:

Risk

Occupations: