New Patient Medical History

NEW PATIENT MEDICAL HISTORY
Patient Name:
Today's Date:

MonthDayYear
Date
Address:
Home Phone:
Work Phone:
Cell Phone:
Employer:
Job:
Age:
Date of Birth:

MonthDayYear
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:
Please list all operations, hospitalizations, broken bones, serious illness:
Hospitalizations/Surgeries
Year
Reason or Problem
Year
Reason or Problem
Year
Reason or Problem
Broken Bones
Year
Reason or Problem
Year
Reason or Problem
Serious Illnesses
Year
Reason or Problem
Year
Reason or Problem
Blood Transfusions
Year
Reason or Problem
Year
Reason or Problem
Pregnancy History
Year
Outcome/Name
Year
Outcome/Name
Year
Outcome/Name
Auto Accidents/Other
Year
Reason or Problem
Drug Allergies or Reactions:
Name of Drug
Reaction
Name of Drug
Reaction
Name of Drug
Reaction
Name of Drug
Reaction
Have you had any of the following?

DiabetesHeart DiseaseCancerEmphysemaBronchitisAsthmaMigraineGoutStrokeColon PolypsKidney DiseaseGallbladder DiseaseHigh Blood PressureVascular DiseaseAllergiesNeurologic DiseaseSerious InfectionUlcer DiseaseThyroid DiseaseSeizures
Vaccinations

Please list the year of last vaccination for the following - If Known
Tetanus and diphtheria:
Shingles:
Pneumonia:
Flu:
Hepatitis A:
Hepatitis B:
Family Medical History:
Is your father living?

YesNo
Father's Age Now or At Death
Father's Medical Problems or Cause of Death
Is your mother living?

YesNo
Mother's Age Now or At Death
Mother's Medical Problems or Cause of Death
Is your sister(s) living?

YesNo
Sister(s) Age Now or At Death
Sister(s) Medical Problems or Cause of Death
Is your brother(s) living?

YesNo
Brother(s) Age Now or At Death
Brother(s) Medical Problems or Cause of Death
Is your daughter(s) living?

YesNo
Daughter(s) Age Now or At Death
Daughter(s) Medical Problems or Cause of Death
Is your son(s) living?

YesNo
Son(s) Age Now or At Death
Son(s) Medical Problems or Cause of Death
Other Relatives:
Is there a family history of:

Colon CancerBreast CancerLung CancerOther CancerUlcersTBAlcoholismStrokeHeart DiseaseDiabetesEmphysemaHigh Blood PressureHigh CholesterolKidney DiseaseColon PolypsGoutAlzheimer's DiseaseCongenital disorders or other serious illnessOther
Tobacco:
Have you ever smoked?

YesNo
Do you smoke now?

YesNo
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?

YesNo
How many times per week?
Alcohol and Drugs:
Do you consume alcohol?

YesNo
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?

YesNo
If you quit, what year?
Have you ever been counseled for alcohol or drug abuse?

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

Yes. If so which one?No
Caffeine:
Do you drink coffee?

YesNo
How many cups per day?
Do you drink other caffeinated drinks (cola, tea etc.)?

YesNo
Exercise:
Do you exercise regulary?

YesNo
If yes, describe:
Sleep:
How many hours do you sleep at night?
Do you snore?

YesNoUnsure
Do you feel refreshed when you awaken in the morning?

YesNo
Weight:
What is your adult normal weight range?
Diet:
Do you limit fat and cholesterol content of foods eaten?

YesNo
Risk
Do you wear seatbelts?

YesNo
Do you have smoke alarms in the home?

YesNo
Do you have a carbon monoxide detector?

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

YesNo
Do you wear ear protection around loud noise?

YesNo
Occupations:

List all jobs held in adult life:
1
What years?
2
What years?
Did someone refer you to our practice?

YesNo
If so, whom?
Is there anything else you would like us to know?
Should be Empty:

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: