New Patient Questionnaire

New Patient Questionnaire
Date

MonthDayYear
Date
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Emergency Contact
Emergency Contact Phone Number
Please enter a valid phone number.
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 PressureHigh CholesterolDiabetesHeart DiseaseStroke/TIAAsthmaBlood ClotsCOPD/EmphysemaOsteoporosisAutoimmune DisorderCancerThyroid DiseaseLiver DiseaseSeizures/EpilepsyDepressionAnxietyOther Mental Health ConditionOther
If cancer, what type?
List any other diagnosis
Past Surgical History

Please list any major surgeries or procedures (Dates if known)

Please list any recent hospitalizations (If not listed above)

List all current medications, including over the counter, vitamins, and supplements

List any additional medications here
Pharmacy Name
Pharmacy Phone Number
Please enter a valid phone number.
Please list any medication or food allergies
Social History
Do you smoke?*

YesNoFormer Smoker
If former smoker, quit date

MonthDayYear
Date
Do you consume alcohol?*

NoOccasionallyFrequently
What is your current living situation?*

Live aloneLive with family or caregiverAssisted LivingOther
Advanced Directives
Do you have any of the following?*

Living WillDurable Power of Attorney for HealthcareDNR (Do Not Resuscitate) OrderNone of the aboveOther
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*

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Past Medical History