New Patient form

Name

First NameLast Name

Person Filling Out This Form (if not the Patient)

First NameLast Name

Relationship to the Patient

Email

example@example.com

Phone Number

Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth

Date

Place of Birth

City/State or Town/Country if not in the US

Gender

Marital Status

Did something trigger your change in health?

Blood type

Do you have insurance?

Do you have secondary insurance?

Upload insurance

Photo ID

Reason For Today’s Visit / Chief Complaint (please describe symptoms)

Please list your reason:

Vaccines

Rows	Yes	No	Unknown
HPV (Gardasil)
Tetanus (TdaP)
Hepatitis A
Hepatitis B
Influenza (Flu)
Pneumonia (Pneumovax)
Chicken pox (Varavax)
Shingles (Zostavax)
Meningitis

Do you have any allergies?

If yes, please list.

Do you have any drug allergies?

If yes, please list.

Have you had the tests below?

Rows	Yes	No	Unsure
Cervical Pap Smear
Anal Pap Smear
HIV Test
Hepatitis C Test

Have you ever been diagnosed with or tested positive for a sexually transmitted disease?

If yes, please check all that apply

Rows	Not Satisfied	Somewhat Satisfied	Satisfied
HIV/AIDS
Gonorrhea
Chlamydia
Oral Herpes
Yeast Infection
Syphilis

To your knowledge, have any of your blood relatives had any of the following section?

Family History

Rows	Mother	Father	Sibling	Children	Mat. Grandparent	Pat. Grandparent
Cancers
Colon
Breast/Ovarian
Heart Disease
Hypertension
Obesity
Diabetes
Stroke
Inflammatory arthritis
Inflammatory Bowel Disease
Multiple Sclerosis
Autoimmune Diseases
Irritable Bowel Syndrome
Celiac Disease
Asthma
Eczema/Psoriasis
Food allergies/sensitivities
Environmental sensitivities
Dementia
Parkinson's
ALS or other motor neuron diseases
Genetic disorders
Substance abuse (alcoholism, etc.)
Psychiatric disorders
Depression
Schizophrenia
ADHD
Austism
Bipolar disease

Surgical History

Rows	Yes	No Satisfied
Appendix Removal
Breast Lumpectomy
Facial Surgery
Hysterectomy
Phalloplasty

Gastroenterology Related Medical History

Rows	Past condition	Ongoing condition	N/A
Irritable Bowel Syndrome
Crohn's
Ulcerative colitis
Peptic Ulcer disease
GERD (reflux)
Celiac disease

Cardiology Related Medical History

Rows	Past condition	Ongoing condition	N/A
Heart Attack
Other Heart disease
Stroke
Elevated cholesterol
Arrhythmia (irregular heart rate)
Hypertension (high blood pressure)
Rheumatic fever
Mitral valve prolapse
Other

Endocrine Related Medical History

Rows	Past condition	Ongoing condition	N/A
Type 1 Diabetes
Type 2 Diabetes
Hypoglycemia
Metabolic syndrome (pre-diabetes)
Hypothyroidism (low thyroid)
Hyperthyroidism (overactive thyroid)
Polycystic Ovarian Syndrome
Infertility
Weight gain
Weight loss
Eating disorder
Other

Nephrology Related Medical History cont.

Rows	Past conditon	Ongoing condition	N/A
Kidney stones
Gout
Interstitial cystitis
Frequent urinary tract infections
Frequent yeast infections
Erectile dysfunction
Sexual dysfunction
Other

Orthopedics Related Medical History cont.

Rows	Past condition	Ongoing condition	N/A
Osteoarthritis
Fibromyalgia
Chronic pain
Other

Immune System Related Medical History cont.

Rows	Past condition	Ongoing condition	N/A
Chronic Fatigue Syndrome
Autoimmune disease
Rheumatoid arthritis
Lupus SLE
Immune deficiency disease
Severe infectious disease
Poor Immune function
Other

Lung Related Medical History

Rows	Past condition	Ongoing condition	N/A
Asthma
Chronic sinusitis
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Sleep Apnea
Other

Cancer History

Rows	Past condition	Ongoing condition	N/A
Eczema
Psoriasis
Acne
Melanoma
Skin Cancer
Other

Cancer History Cont.

Rows	Past condition	Ongoing condition	N/A
Lung cancer
Breast cancer
Colon cancer
Ovarian cancer
Prostate cancer
Skin cancer
Other

Mental Health Condition History

Rows	Past condition	Ongoing condition	N/A
Depression
Anxiety
Bipolar disorder
Schizophrenia
Headaches
Migraines
ADD/ADHD
Autism
Memory problems
Dementia/Alzheimer's
Parkinson's disease
Multiple Sclerosis
Seizures
Other

Please list any significant physical trauma you've experienced

Please list emotional trauma you've experienced in your life

Gynecological History

Gynecological History cont.

Rows	Present use	Past use	Never
Birth control pills
Hormonal patches
Nuva Ring
Condom
Diaphragm
Hormonal IUD
Non-hormonal IUD
Partner Vasectomy

Gynecological History cont.

Menopausal patients

Men's history

Dental history

Medication history

Rows	Currently	Past use	Rarely used	Never
NSAIDs (Advil, Motrin, Ibuprofen, Aspirin, etc.)
Tylenol (Acetaminophen)
Acid blockers (Tagamet, Zantac, Prilosec, etc.)
Antibiotics
Steriods
Oral contraceptives

Medications

Supplements

Medical Intake form

Insurance Information

Onset/Injury Date

Allergies

Medical History

Medical Health