• New Patient Medical History

    Please complete this form prior to your first appointment
  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Last Physical Exam:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sex

  • Personal Health History

  • Immunizations (Include approximate year or age)
    Rows
  • Past or Present Medical History: (check all that apply to you)
  • Screening Tests
    Rows
  • Glasses
  • Allergies/Reactions to Medications:
  • Medications: List prescribed and over the counter medications.
  • Surgeries (Include year or age at time of surgery)
    Rows
  • Cataract Surgery:
  • Breast Surgery:

  • Health Habits and Personal Safety

  • Alcohol

  • Do you drink alcohol?
  • How much?

  • Each week, how many:
    Serving a beer?     
    Glasses of wine?     
    Shots/mixed drinks?     

  • When did you last have more than 4 drinks in one day?
  • Do you feel you should cut down on drinking?
  • Do people annoy you by nagging about your drinking?
  • Have you ever felt guilty about drinking?
  • Have you ever had a morning drink to steady your nerves?

  • Drugs

  • Have you used recreational or street drugs within the last 2 years?
  • Have you ever used recreational drugs with a needle?

  • Personal Safety

  • Family Health History

  • Family Member - Parents
    Rows
  • Family Member - Siblings
    Rows

  • Reviewed by:______________________________________________________

    Date:

  • Past Medical History

  • Condition / Disease
    Rows

  • Past Surgical Procedures

  • List operation and Month/yr

  • Medication Allergies or Intolerances

  • List below medications causing an allergic reaction (i.e., rash, swelling) or intolerance (i.e., nausea)

  • Medications, Vitamins and Herbal Supplements

  • Social, Educational and Work History

  • Marital Status
  • Children?
  • Work Status
  • Do you drink alcohol?
  • Are you a former smoker?
  • Are you sexually active?
  • Do you have sex with
  • Do you have a Medical Power of Attorney?
  • Format: (000) 000-0000.
  • Do you have a living will?

  • Family Health History

  • Please list below the health history of your blood (genetic) first degree relatives
    Rows

  • Review of Systems

  • Please review the following symptoms and circle those items that are a problem for you

  • Disease Prevention and Health Maintenance

  • Please list below the most recent dates of your vaccines and health screening tests
    Rows
  • Should be Empty: