New Patient Health History

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

New Patient Health History

Family Medical History