Patient Name: ___________________ Date of birth:
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Patient Intake Information
GENERAL MEDICAL HISTORY/FAMILY HISTORY
(P=Patient, F=Family Member) Please check if you or your family has a history of:
P
F
P
F
P
F
Alcoholism
Allergies/Hayfever
Anemia
Depression
Diabetes --on insulin
Diabetes-- not on insulin
Joint Pain
Kidney Infections
Kidney stone
Anxiety
Asthma
Irregular Heart Rhythm
Blood Transfusions
Blocked blood vessels
Epilepsy or seizures
Fracture
Stomach ulcer
Gastrointestinal Disease
GERD/Reflux
Gestational (pregnancy)
Diabetes
Glaucoma
Migraine
Multiple Sclerosis
Obesity
Heart Attack
Arthritis
Heart Murmur
Hepatitis
High Cholesterol
Hyperlipidemia
Lung Disease
Rheumatic Fever
Rheumatoid Arthritis
Sexually Transmitted Disease
High Blood Pressure
Thyroid Disease
Hyperthyroidism
Hypothyroidism
Suicide Attempt
Tuberculosis
Cancer
Heart Disease
Congestive Heart Failure
Cirrhosis or liver disease
Colitis
COPD or emphysema
Chronic kidney
disease/dialysis
Crohn’s Disease
Stroke
Osteoporosis
Pneumonia
OTHER MEDICAL
HISTORY
HOSPITALIZATIONS
MEDICATIONS
DRUG ALLERGIES
REACTION:
TOBACCO ASSESSMENT
Do you smoke?
Have you ever smoked?
Yes
No
Yes
No
Date you quit: _________
Have you ever tried to stop?
SOCIAL HISTORY
Complete the following:
Do you use Alcohol?
Do you use caffeine?
Drug Use at any time?
IV Drug Use at any time?
Do you use sun protection
(sunscreen)?
Do you have Tattoos?
Are you Sexually active?
Religion
How many packs per day?
How many years?
Yes
No
If Yes:
__drinks per __
__ drinks per __
Complete the following:
Educational Level
No
No
Yes
Yes
No
No
No
Yes
Yes
Yes
Describe:
Describe:
No
No
Yes
Yes
Birth Control Methods
Language spoken
Occupation
Marital Status (circle)
Exercise Habits
Do you always wear Seatbelts?
No Yes
Do you have Body piercings?
Single Married Separated
Divorced Widowed
No
Yes
Patient Name: ___________________ Date of birth:
Race (please circle)
/
/___
African/American - Asian - Ashkenazi - Caucasian - Hispanic - Mediterranean -Native American - other
Have you been abused
No
physically?
Have you been a victim of
No
domestic violence?
Any additional Social History:
Yes
Yes
Depression Screening
Do you have little interest or pleasure in doing things?
Do you feel down, depressed or hopeless?
If yes to above questions, please explain:
No
No
Yes
Yes
SURGICAL/PROCEDURAL
No prior surgical history
D&C
Hysterectomy
Appendectomy
Endometrial Ablation
Laparoscopy
Breast Lumpectomy
Gall Bladder
Mastectomy
Cataract Surgery
Heart Surgery
Uterine fibroid removal
Removal of Colon
Hemorrhoids
Removal of Ovaries
Biopsy of Cervix (Cone biopsy)
Hernia
Tonsil/Adenoidectomy
Other Surgical History
Tubal Ligation
FOR FEMALE PATIENTS:
OB/GYN HISTORY
Last menstrual period:
How often are periods:
Has Menopause started?
Have you had abnormal pap smears?
Any ectopic (tubal) pregnancies?
Age periods started:
Days of bleeding each cycle:
No Yes If yes, what age were you:
No Yes If yes, when?
No Yes If yes, when?
PREGNANCY SUMMARY
# Of Pregnancies
Miscarriage(s)
Term
Elective
Abortion(s)
Preterm
C-Section(s):
Live Children