New Patient Questionnaire
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Emergency Contact
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Relationship
Current Primary Care Provider (If any)
Specialty Providers
List any specialty providers such as Cardiology, Urology, Podiatry, GI, etc
Past Medical History
Please check all diagnosis that apply:
*
High Blood Pressure
High Cholesterol
Diabetes
Heart Disease
Stroke/TIA
Asthma
Blood Clots
COPD/Emphysema
Osteoporosis
Autoimmune Disorder
Cancer
Thyroid Disease
Liver Disease
Seizures/Epilepsy
Depression
Anxiety
Other Mental Health Condition
Other
If cancer, what type?
List any other diagnosis
Past Surgical History
Please list any major surgeries or procedures (Dates if known)
Rows
Date
Hospital Name
Surgery/Procedure
1
2
3
Hospitalizations
Please list any recent hospitalizations (If not listed above)
Rows
Date
Hospital Name
Reason
1
2
3
Hospital Documentation File Upload
Browse Files
Drag and drop files here
Choose a file
Please upload hospital documents if available
Cancel
of
Medication List
List all current medications, including over the counter, vitamins, and supplements
Rows
Medication Name
Dosage
Frequency
Reason for taking
1
2
3
4
5
List any additional medications here
Pharmacy Name
Pharmacy Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Please list any medication or food allergies
Social History
Do you smoke?
*
Yes
No
Former Smoker
If former smoker, quit date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you consume alcohol?
*
No
Occasionally
Frequently
What is your current living situation?
*
Live alone
Live with family or caregiver
Assisted Living
Other
Advanced Directives
Do you have any of the following?
*
Living Will
Durable Power of Attorney for Healthcare
DNR (Do Not Resuscitate) Order
None of the above
Other
Power of attorney documentation must be submitted in order to list the POA in the patient's chart.
Advanced Directive File Upload
Browse Files
Drag and drop files here
Choose a file
Please upload any documentation and/or records here
Cancel
of
Reason for your visit
Briefly describe the reason you are seeking care from Homedica House Calls
*
Is there anything else you would like your provider to know?
Patient/Responsible Party Signature
*
Continue
Continue
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