New Patient Form
Name:
*
First Name
Middle Initial
Last Name
Name you go by:
Cell # :
*
Format: (000) 000-0000.
Date of Birth:
*
/
Month
/
Day
Year
Date
Email:
*
example@example.com
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Personal Medical History (PMHx)
*
Heart Disease (CAD)
High Blood Pressure (HBP)
Diabetes (DM)
Stroke (CVA)
Cancer (CA)
Other (Please explain or put N/A)
Occupation
*
Is your occupation physically demanding?
*
Yes
No
Medications that you are currently taking:
*
Work Address
Work#:
Marital Status: (Please circle one)
*
Single
Married
Widowed
Divorced
Surgeries:
*
Spouse's information:
Name
Cell Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Allergies:
*
Back
Next
Mark X for YES if symptom is present, or if a history of the condition exists. Mark X for NO if not.
*
Rows
YES
NO
Shortness of breath (at rest)
Shortness of breath (activity)
Night sweats
Productive cough
Bloody cough
Tuberculosis
Pneumonia
Asthma
Pulmonary emboli
Emphysema
Chest pain
High blood pressure
Heart attack
Angina
Heart failure
Heart murmur
Mitral valve prolapse
Low blood pressure
Edema
Peripheral vascular disease
Medical History Questionnaire
Mark X for YES if symptom is present, or if a history of the condition exists. Mark X for NO if not.
*
Rows
YES
NO
Nausea
Vomiting
Abdominal pain
Black stools
Rectal bleeding
Heartburn
Belching
Constipation
Diarrhea
Hemorrhoids
Ulcer disease
Gallstones
Colitis
High cholesterol
High lipids
Nighttime frequent urination
Urgency
Difficult urination
Burning on urination
Infertility
Enlarged prostate (men)
Bloody urine
Recurrent urinary infection
LIST ALL PAST HOSPITALIZATIONS:
*
Back
Next
*
Rows
YES
NO
Aching muscles / joints
Low back pain
Limitations on mobility
Arthritis
Muscle cramps
Numbness
Dizziness
Headaches
Epilepsy
Seizure disorder
Fainting
Visual limitations
Hearing limitations
Diabetes
Gout
Thyroid
Depression
Bipolar/manic depression
Schizophrenia
Glaucoma
Anemia
WEIGHT HISTORY:
Age of onset of weight problem
*
Number of weight loss attempts over last 5 years
*
Date of last weight loss attempt
*
/
Month
/
Day
Year
Date
Method
*
Outcome
*
Lowest weight: 5 years
*
: 10 years
*
Highest weight: 5 years
*
: 10 years
*
Women Current Dress size
Men current waist size
FAMILY HISTORY: mother/father/brother/sister
WOMEN - PLEASE ANSWER:
Cancer
Last menses
Heart disease
Post-menopausal (y/n)
High blood pressure
Last pap smear
Lung disease
Last breast exam
Psychiatric disease
Birth Control (y/n-drug)
Pregnancies
Miscarriages
Abnormal female bleeding (y/n)
Are you breast feeding (y/n)
PLEASE READ THIS CAREFULLY
I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO NOTIFY DR. FOLEY OF ANY COMPLICATIONS OR UNUSUAL PROBLEMS THAT I AM HAVING WITH THIS PROGRAM AND IMMEDIATELY DISCONTINUE MEDICATIONS AND SUPPLEMENTS UNTIL DR. FOLEY REVIEWS MY SITUATION. I WLL NOTIFY DR. FOLEY IF MY HEALTH STATUS CHANGES FOR ANY REASON OR IF MY FAMILY DOCTOR PRESCRIBES MEDICATIONS OR ANY TREATMENT FOR ANY DISEASE OR ILLNESS PREVIOUSLY NOT REPORTED TO DR. FOLEY'S OFFICE ON MY PERMAMENT RECORD. I WILL INFORM MY FAMILY DOCTOR OF PRESCRIPTION MEDICATIONS I AM TAKING FROM DR. FOLEY.
I HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE AND WILL ASSUME FULL RESPONSIBILITY FOR RELATING MY MEDICATIONS TO DR. FOLEY. I AUTHORIZE THE RELEASE OF MY MEDICAL RECORDS TO DR. FOLEY.
SIGNED:
*
DATE:
*
/
Month
/
Day
Year
Date
MY FAMILY DOCTOR:
ADDRESS
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