New Patient Health History

New Patient Health History
Patient Name

First NameLast Name
Date

MonthDayYear
Date
Reason for visit
Date of Birth

MonthDayYear
Date
Age
Primary Care Provider
Marital Status
Past Medical History: (Check all that apply)
Any other health issues?:
Please separate by comma
Gynecologic/Obstetric History: have you ever had any of the following? (Check all that apply)
Check if you are up to date with the following vaccinations and the year received.

SURGICAL HISTORY

SURGICAL HISTORY - CONTINUED

CURRENT MEDICATIONS AND SUPPLEMENTS

CURRENT MEDICATIONS AND SUPPLEMENTS - CONTINUED

Medications you are allergic to:
Allergic to:
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

MonthDayYear
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?
Amount
Amount
Do you use tobacco?
Tobacco - amount used
Name

First NameLast Name
DOB

MonthDayYear
Date
REVIEW OF SYSTEMS: Please check any symptoms that have troubled you during the last several weeks.

Family Medical History