New Patient Health History Form

The day your last period started

Routine PhysicalProblem

AnemiaAnxietyArthritisAsthmaBlood clotting disorderBlood transfusionBreast diseaseCancerDepressionDiabetesEating disorderFrequent infectionsBowel condition (IBS, colic, Crohn's disease)GlaucomaHeadachesHeart diseaseHepatitisHigh cholesterolHigh blood pressureKidney infectionKidney stoneOsteopenia/OsteoporosisEpilepsy/seizuresKidney diseaseRheumatic feverRecurrent UTIsPsychiatric illnessStrokeSexually transmitted diseaseSkin disorderThyroid disorderTuberculosis (TB)Hemophilia or other bleeding disorderOther

	Allergy	Reaction	Severity
1
2
3
4
5

	Name	Dose	Frequency	Who prescribes?
1
2
3
4
5
6
7

NoMildModerateSevere

NoneLess than 3 times per weekMore than 3 times per week

HusbandLess than 5More than 5

Never smokerCurrent smokerFormer smoker

Lifetime abstainer: fewer than 12 drinks in lifetimeFormer infrequent drinker: Fewer than 12 drinks in any 1 year, none in the past yearFormer regular drinker: At least 12 drinks in any 1 year, no drinks in the past yearCurrent infrequent drinker: 1-11 drinks in the past yearCurrent light drinker: at least 12 drinks in the past year, but 3 or fewer per weekCurrent moderate drinker: More than 3 drinks but not more than 7 per week on averageCurrent heavy drinker: More than 7 drinks per week on average in past year

NonePhysicalEmotionalSexual

NormalOsteopeniaOsteoporosis

New Patient Health History Form

PAST MEDICAL HISTORY

SURGICAL HISTORY

GYNECOLOGIC HISTORY

OB HISTORY

Fill in the information below about each of your pregnancies

SOCIAL HISTORY

ROUTINE HEALTH SCREENINGS

FAMILY HISTORY