twinsburgmed.com - Established Patient Form

1

Patient's Name* This field is required.

2

Date of Birth:* This field is required.

Date

3

How would you describe your OVERALL HEALTH:* This field is required.

Excellent

Fair

Poor

4

Ever been hospitalized?* This field is required.

Yes

No

5

Is so, what for and what year?

6

Any implantable devices?* This field is required.

Yes

No

7

Year implanted?

8

Do you have any concerns regarding SAFETY at home?* This field is required.

Yes

No

9

If yes, explain:* This field is required.

10

Household smoke detector?* This field is required.

Yes

No

11

Firearms in home?* This field is required.

Yes

No

12

If yes, are they locked in a safe place?

Yes

No

13

What gender or pronoun you identify as?

14

In a relationship?

Yes

No

15

For a relationship, I prefer:* This field is required.

Male

Female

Both

Other

16

Sexually active?

Yes

No

17

Pregnant or Trying to get pregnant?

Yes

No

18

Breastfeeding?

Yes

No

19

Any form of contraception (including hysterectomy & vasectomy)?

Yes

No

20

Type:

21

Describe OVERALL DIET: * This field is required.

Well-balanced

Typical American Diet

Vegetarian/Vegan

Other

22

Regular EXERCISE ROUTINE?:* This field is required.

Yes

No

23

Daily Hours of SLEEP: * This field is required.

24

WATER ounces daily: * This field is required.

25

Do you consume CAFFEINE?* This field is required.

Yes

No

26

If yes, how often?

27

Do you consume JUICE OR SODA?* This field is required.

Yes

No

28

If yes, how often?

29

Have you seen a dermatologist for a yearly skin exam?

Last date & dermatologist office name

30

In the last year visited:

31

DENTIST? * This field is required.

Yes

No

32

EYE DOCTOR? * This field is required.

Yes

No

33

OTHER MEDICAL PROVIDERS? If so, list name and specialty?

34

Do you have an ADVANCED DIRECTIVE/LIVING WILL/DPOA on file?* This field is required.

Yes

No

35

History of HIGH CHOLESTEROL?* This field is required.

Yes

No

36

Ever been treated for it?* This field is required.

Yes

No

37

History of HIGH BLOOD PRESSURE? * This field is required.

Yes

No

38

Ever been treated for it?* This field is required.

Yes

No

39

History of DIABETES or PREDIABETES? * This field is required.

Yes

No

40

Ever been treated for it?* This field is required.

Yes

No

41

Feeling down, depressed or hopeless?* This field is required.

Yes

No

42

Have you lost interest or pleasure in doing things?* This field is required.

Yes

No

43

Are you:* This field is required.

Men

Women

44

Women: Are you.....

45

Pregnant/Trying to get pregnant?

Yes

No

46

Taking oral contraceptives

Yes

No

47

Nursing

Yes

No

49

Would you like STD screening (mainly for Gonorrhea, Chlamydia, Syphilis, or HIV)? * This field is required.

Yes

No

50

History of being tested for HEPATITIS or exposure to someone with hepatitis?* This field is required.

Yes

No

51

Have you ever been screened for lung cancer by a low dose CT-scan? * This field is required.

Yes

No

52

If yes, results?

53

Have you completed a colonoscopy in the past?* This field is required.

Yes

No

54

Year?

55

Abnormal?

56

FOR MALES ONLY:

57

Ever been screened for prostate cancer?

Yes

No

58

Year?

59

Abnormal?

60

Ever been screened for an abdominal aortic aneurysm?

Yes

No

61

Year?

62

Abnormal?

63

FOR FEMALES ONLY:

64

Do you have periods?

Yes

No

65

Date of last menstrual period?

66

Do they occur monthly?

Yes

No

67

Describe:

68

Number of total pregnancies?

69

Total live births & year?

70

Vaginal or C-Section & year?

71

How many abortions & year?

72

Have you ever completed a pap smear test?

Yes

No

73

Last test date?

74

Abnormal or HPV positive?

Yes

No

75

Year?

76

Abnormal?

77

Colposcopy test completed?

Yes

No

78

Have you ever completed a mammogram?

Yes

No

79

Year?

80

Abnormal?

81

If 65 years or older, have you completed a DEXA scan?

Yes

No

82

Year?

83

Abnormal?

84

By Signing here, I state that the above information has been answered to the best of my knowledge. I understand that providing incorrect information can be dangerous to my (or patient’s) health.

85

Signature of Patient or Personal Representative* This field is required.

Type Name

86

If not self, Personal Representative’s relationship to patient

87

Date:* This field is required.

Date