New Patient Health History
Patient Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Reason for visit
Date of Birth
-
Month
-
Day
Year
Date
Age
Primary Care Provider
Marital Status
Past Medical History: (Check all that apply)
Asthma
Blood Clots
Depression
Diabetes
Epilepsy/Seizures
Heart Disease
High Blood Pressure
High Cholesterol
Kidney/Liver Disease
Migraines
Osteoporosis
Thyroid Disease
Any other health issues?:
Please separate by comma
Gynecologic/Obstetric History: have you ever had any of the following? (Check all that apply)
Abnormal Pap Smear
Endometriosis
Fibroids
Frequent Bladder Infections
Genital Warts
Gonorrhea or Chlamydia
Herpes
HIV
Infertility
Pelvic Inflammatory Disease
Pelvic Pain/Pressure/Bloating
Urinary Incontinence
Check if you are up to date with the following vaccinations and the year received.
Flu
Hepatitis B
Pneumonia
Rubella (measles)
Tdap
Tetanus
SURGICAL HISTORY
Type of Surgery
Year
Surgery #1
Surgery #2
SURGICAL HISTORY - CONTINUED
Type of Surgery
Year
Surgery #3
Surgery #4
Surgery #5
Surgery #6
Surgery #7
Surgery #8
CURRENT MEDICATIONS AND SUPPLEMENTS
Name of Medication
Dose
#1
#2
CURRENT MEDICATIONS AND SUPPLEMENTS - CONTINUED
Name of Medication
Dose
#3
#4
#5
#6
#7
#8
Medications you are allergic to:
Allergic to:
Latex
Eggs
Iodine
Family Medical History
Mark M for Mother, F for Father, S for Sister, B for Brother, A for Aunt, U for Uncle, PGP for Paternal Grandpa, PGM for Paternal Grandma, MGP for Maternal Grandpa, and MGM for Maternal Grandma. Add ages if possible.
Blood Clots
Breast Cancer
Colon Cancer
Diabetes
Heart Attack
High Blood Pressure
High Cholesterol
Melanoma
Osteoporosis
Ovarian Cancer
Prostate Cancer
Stroke
Uterine Cancer
Family Medical History: Other
Age of First Period:
First Day of Last Period
-
Month
-
Day
Year
Date
Length of menstrual cycles
Length of each period
Heavy Periods?
Painful Periods?
Last Pap smear
Number of Pregnancies
Full Term/ Premature deliveries
Number of Abortions
Number of Miscarriages
Number of living children
Last Mammogram
Last Colonoscopy
Are you planning a pregnancy in the next year?
If applicable, what are you using for birth control?
Do you have any questions/concerns about your sexual life?
Personal Health History: Occupation:
What do you do for exercise?
Have you ever been physically, emotionally, or sexually abused?
Do you drink alcohol?
Y
N
Amount
Amount
Daily
weekly
monthly
Do you use tobacco?
former
never
current
Tobacco - amount used
Name
First Name
Last Name
DOB
-
Month
-
Day
Year
Date
REVIEW OF SYSTEMS: Please check any symptoms that have troubled you during the last several weeks.
FATIGUE
UNEXPLAINED WEIGHT LOSS
UNEXPLAINED WEIGHT GAIN
VISION PROBLEMS
SORE THROAT
HEADACHE
SINUS CONGESTION
NASAL DISCHARGE
EAR ACHE
CHEST PAIN
HEART PALPITATIONS/FLUTTERS
SWELLING IN FEET
COUGH
COUGHING UP BLOOD
SHORTNESS OF BREATH
WHEEZING
NAUSEA
DIARRHEA
RECTAL BLEEDING
ABDOMINAL PAIN
VOMITING
CONSTIPATION
BLACK, TARRY STOOLS
HEARTBURN
BLOATING
HEMORRHOIDS
BLOOD IN URINE
HEAVY PERIODS
VAGINAL DISCHARGE
PAINFUL URINATION
BLEEDING BETWEEN PERIODS
PELVIC PAIN
LEAKING OF URINE
BLEEDING WITH INTERCOURSE
MUSCLE ACHES
JOINT ACHES
SKIN RASHES
BREAST PAIN
BREAST DISCHARGE
HEADACHE
FAINTING
SEIZURES
WEAKNESS
NUMBNESS
DEPRESSION
ANXIETY
HEAT INTOLERANCE
NIGHT SWEATS
COLD INTOLERANCE
HOT FLASHES
EASY BRUISING
SWOLLEN GLANDS
SEASONAL ALLERGIES
FEVERS
CHILLS
CHECK HERE IS NONE OF THE ABOVE APPLY
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Surgical History: Write year and type of surgery
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