NEW PATIENT HEALTH HISTORY FORM
Patient Name
Birth date
/
Month
/
Day
Year
Date
Date
/
Month
/
Day
Year
Date
Referring Physician
Address
Pharmacy Name
Phone Number
Reason for today's visit
Please describe this problem
CURRENT/PRIOR ILLNESSES/INJURIES
Please list ALL medications (prescription and non- prescription) that you take. (Include herbal remedies, vitamins, overthe-counter, street drugs, prescriptions etc.) Include Dosage
Do you take any blood thinning products such as Vitamin E, Plavix, Coumadin, or Aspirin?
NO
YES
Prior Surgeries
List Surgery
Current/Prior Illness/Injuries
Prior surgery
Prior surgery
Prior surgery
Prior surgery
Do you have any food, environmental, or drug allergies?
NO
(Please explain below)
YES
Food, environmental, or drug allergies?
Do you smoke?
YES (Please explain below)
NO and Never have
TYPE OF SMOKING (cigarette, pipe marijuana, chew, etc)
How Much
How Long
Do you drink alcohol?
Socially Only
Daily
Beer/Wine
Hard Liquor
No and Never Have
Occupation
Hand Dominance
RIGHT
LEFT
Please describe any family health issues below:
Back
Next
Patient Signature
Date
/
Month
/
Day
Year
Date
Physician Signature
Date Reviewed
/
Month
/
Day
Year
Date
Do you have or have you ever had any of the following?
No
Yes, Explain
Fever or chils
Weight loss
Hepatitis
HIV/Other blood diseases
Bleeding Disorders
Thyroid Problems
Diabetes
Arthritis
Mobility/ Joint Problems
Constipation
Diarrhea
Blood in Stool
Nausea/ Vomiting
Liver Problems
Heart Problems
Deep Vein Thrombosis/ DVT
Blood Clots in Lungs/ Legs
High Blood Pressure
Asthma
Sleep Apnea
Breast Abnormalities
Nipple Discharge
Changes in Moles
Lesions
Rashes
History of Keloids
Neurological Problems
Headaches
Genital or Oral Herpes
S.T.D.’s
Blood in Urine
Urinary Tract Infection
Problems Urinating
Prostate Problems
Kidney Problems
Vision Problems
Hearing Problems
Sinus Problems
Mood Swings
Anxiety/ Depression
Please list any other conditions/ illnesses not indicated above
To the best of my knowledge, this information is complete and correct. I understand that it is my responsibility to inform my doctor if there are any changes to my health
Patient Signature
Date
/
Month
/
Day
Year
Date
Physician Signature
Date Reviewed
/
Month
/
Day
Year
Date
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