Dr Yates New Patient Assessment

Dr. Yates New Patient Assessment
Please complete at least 24 hours before your New Patient Appointment

This is a comprehensive form and will take approximately 20-40 minutes to thoroughly complete.

The submission can be saved and returned to complete. Click the "Save" button to save your progress for later. You will receive an email with a link to continue to progress.

DATE

MonthDayYear
Date
Full Name*
First and Last Name
Date of Birth*

MonthDayYear
Date
Current Age
Preferred Contact Telephone Number*
Email Address*
example@example.com
How did you hear about Dr. Yates?*
If you were referred by another physician or an individual, what is their name?*
Is the person who referred you an existing patient of Dr Yates?

YesNo

What is your gender?*

FemaleMale
What is your current marital status?*

SingleMarriedSignificant OtherDivorcedWidow/Widower
What is your height in inches?*
Eg: 5'10" = 70 inches; 5'3" = 63 inches, 6'2" = 74 inches, etc
How much do you weigh in lbs?*
Eg: 127, 207
BMI*

Family History

The next 9 questions provide details of your family history.

Please be as descriptive as possible in your answers. Thank you!
What is your current work? *

Include information if you work multiple jobs, attend school or after-work classes, etc0/500
Do you profess a religion or faith?*

If you feel comfortable, feel free to tell us about it (not required)0/500
Are your biological parents alive? *

0/450
Do/did your biological parents suffer any diseases?*

Eg: cancer, diabetes, high blood pressure, etc0/450
Are there any disease which "run in the family"?*

Eg: Two uncles had colon cancer, grandparents had Alzheimers, etc0/450

Do you have any children? If so, how many? Do any of them suffer any diseases?*

Eg: cancer, diabetes, high blood pressure, etc0/450
Do you smoke? (Cigarettes/cigars/vaping) If so, how many packs per week or how often?*

Eg: 2 packs per week, a cigar at special occasions, 60ml vape per week 0/500
Do you consume alcohol? If so, how many drinks per week?*

0/500
Are you currently under any dietary restrictions? Please explain: doctor's orders, on a diet plan? Detail any restrictions if applicable*

0/1250

Please describe your last 3 meals. Was it prepared at home from raw ingredients, purchased pre-packaged and warmed up, or was a restaurant or fast food joint? What time of day was the meal? How large were your portions? Please be descriptive.*

0/2100

Tell us about your activity levels. Do you participate in any exercise on a routine basis? If so, what kind? (walking, jogging, gym workout?) Does your job require a lot of walking or standing, or are you primarily seated? Please be descriptive. *

0/2200

Please enter current prescription or OTC medications

Please enter current supplements, shakes, or medicated creams you currently use

Have you been diagnosed with any diseases?

	Disease name	Approximate Date of Diagnosis month/year if recent year only if more than 2 years ago
1.
2.
3.
4.
5.
6.
7.
8.
9.

Have you ever been hospitalized?

	Approximate date of Hospitalization and where	How long was the hospital stay?	For what reason?
1.
2.
3.
4.
5.
6.
7.

Please list all surgeries you have ever had (including organ removal, joint surgeries, c-sections, etc)

	Type of Surgery	Approximate Date of Surgery month/year if recent year only if more than 2 years ago)
1.
2.
3.
4.
5.
6.
7.
8.
9.

Allergies: Please list any medication, food, animals, or other things to which you are allergic

	0	1	2	3
Constipation
Goiter
Cold body temperature
Hoarseness
Hair dry or brittle
Nails breaking or brittle
Slow pulse rate
Rapid heartbeat
Heart Fluttering/palpitations
Cold extremities

Dr. Yates New Patient Assessment