Patient History
Date_________________
Name______________________________________________Age______Date of Birth______________ Phone ______________
Recent Primary Care Physician___________________Are you Changing Primary Care to This facility: Y/N
Current Medication: If you are a returning patient with no change to medication check here---------------------------Name
Strength (i.e. 25mg) Amount (i.e. 1 tab…)
Frequency (Once in AM, twice a day…)
30/90 day supply
Past Medical History: If you are a returning patient with no change to History check here-------------------------------Check all that apply to you, list additional in remaining boxes
Asthma
Blood Transfusion
Heart Murmur
Glaucoma
Sleep Apnea
Heart Disease
Angina
Cancer________
Heart Attack
GERD
Blood Clot
Thyroid
Arthritis
Chronic Pain
High Blood Press
Kidney Stone
Colitis
Diabetes
Aneurysm
Cirrhosis
High Cholesterol
Pancreatitis
HIV/AIDS
Anemia
Emphysema/COPD
Hepatitis _____
Stroke
Ulcers
A. Fib
Diverticulosis/itis
Hearing Loss
Tuberculosis
Allergies
Immunizations: If you are a returning patient with no change to Immunizations check here------------------------------Year
Year
Year
Year
Other
Flu
Pneumovax (Pneumonia)
ZostaVax (shingles)
Tetanus / TdaP
Hepatitis A
Hepatitis B
Medication Allergies: If you are a returning patient with no change to allergies check here------------------------------Medication
Reaction
Medication
Reaction
Medication
Reaction
Surgical History: If you are a returning patient with no change to surgical history check here----------------------------Surgery
Year
Surgery
Year
Surgery
Year
Colonoscopy
Hospitalization: If you are a returning patient with no hospitalizations since last visit check here----------------------Date
Reason
Date
Reason
Family History: If you are a returning patient with no change to family history check here-------------------------------Arthritis
Blood Press
Colon Cancer
Stroke
Blood Clots
Cholesterol
Breast Cancer
Melanoma
Diabetes
Heart disease
Prostate cancer
Thyroid
Social History: If you are a returning patient with no change to social history check here------------------------------------Marital Status
Tobacco Use
None/Current/Former
Employment Status
Alcohol Use
None/Current/Former
Number of Children
Recreational Drug Use
None/Current/Former
Gynecological History: If you are a returning patient with no change to gyn history check here------------------------Date
Date
Date
Last PAP
Last Mammogram
Last Bone Density Scan
Patient/Guardian Signature ____________________________________By signing I acknowledge that above information is correct to the best of my knowledge.
Patient History
Date_________________
Name____________________________________________
Date of Birth_____________
To help your appointment flow in a timely fashion and avoid overlooking issues, please list the 4 issues you wish to address in
your time with the doctor today: (i.e. follow up on blood pressure, sore throat…)
1.___________________________________________________2.________________________________________________
3.___________________________________________________4.________________________________________________
Please Circle all that apply to the above listed complaints and to today’s visit:
Constitutional
Chills
Fatigue
Eyes
Blurring of vision
Ear pain
Runny Nose
Ears, Nose, Mouth & Throat
Fever
Weight loss/Gain
Change in vision
Hearing loss
Eye Drainage
Nasal congestion
Sore throat
Nose bleeds
Sputum Production
Wheezing
Respiratory
Cough
Shortness of breath
Cardiovascular
Leg swelling
Chest pain
Cold extremities
Gastrointestinal
Black stools
Diarrhea
Blood in stool
Heartburn
Change in bowel habits
Nausea
Female Reproductive
Vaginal discharge
Hot flashes
Vaginal itching
Irregular menses
Male Reproductive
Difficulty with erection
Genitourinary
Painful urination
Urinary retention
Muscle pain
Musculoskeletal
Rash
Integumentary (Skin)
Palpitations
Breast lumps
Constipation
Vomiting
Nipple discharge
Testicular pain or swelling
Frequent Urination
Blood in urine
Urinary urgency
Joint pain
Itching
Joint Swelling
Back pain
Suspicious Mole
Neurological
Numbness
Dizziness
Slurred speech
Headache
Burning pain in feet
Memory loss Tremor
Psychiatric
Anxiety
Depression
Insomnia
Endocrine
Cold intolerance
Heat intolerance
Excessive thirst
Excessive urination
Confusion
Weakness
Suicidal Thoughts
Hair changes