NEW PATIENT MEDICAL HISTORY FORM

NEW PATIENT MEDICAL HISTORY FORM
Today's date

MonthDayYear
Date
Current PCP
PATIENT INFORMATION
Patient's Last Name
First
Title

Mr.MissMrs.Ms.
Date of Birth

MonthDayYear
Date
Reason/s of Visit
Past Medical History: (known medical diagnosis. Example: Hypertension, Congestive Heart Failure, etc)
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Allergies: (include medications, foods, xray dyes, etc.)
No known allergies

Current Medication: (include prescriptions, over the counter & herbal medications, etc)

Previous Hospitalizations: (include all nonsurgical hospitalizations. Please attached extra sheet if needed)

Past Surgical History (if any):

Cigarette/Tobacco smoker?

YesNo
Alcohol?

YesNo
Drugs?

YesNo
If Yes, please specify
Activity of Daily Living: (Any activity in a day - Example: Cooking, doing Laundry, driving. etc)
FAMILY HISTORY (if any): (include any known family illness)
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Current Health Concerns: Any symptoms such as pain, weight loss, fatigue, Shortness of breath, chest pain, dizziness etc.
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Mental Health

	Yes	No
Anxiety
Depression
Difficulty of Sleeping/ Concentrating
Hx of Physical/Mental Abuse
Mood Swings
Stress
Suicidal

Are you in use of any of the following assistive device?