Dr. Russell NEW PATIENT GENERAL ENDOCRINE
Name: ________________________________________ Date of Birth: __________________
Primary Care Physician: __________________________
Reason for your visit today:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Illness/Medical History
Diabetes
Heart Disease
Thyroid Disease
Adrenal Disorder
Pituitary Disease
Osteoporosis
Calcium problem
Kidney disease
Stroke
Cancer (and what type)
High blood pressure
High cholesterol
Other
Yourself
Family Members
Details
Please list any former surgeries and dates if known:
Surgeries:
Date:
Please list all medications, INCLUDING over the counter and herbal medications, with doses if known:
Medication
Dose
Frequency
1
Are you allergic to any medications? If so, what reaction did you have? _________________________
Social History:

Current smoker, if checked, how much and for how many years? _________________________

Smoked in the past, If checked, how much and for how many years? ______________________

Drink alcohol, If checked, how much and how often? ___________________________________
Marital Status: _________________________
Are you sexually active?
 Yes
 No
For women only: Are you currently or in the near future interested in becoming pregnant?
 Yes
 No
Review of systems:
Please circle any CURRENT symptoms you are having on a FREQUENT basis
General
Head
Neck
Heart
Lungs
Gastrointestinal
Urinary
Reproductive
Skin
Blood
Endocrine
Musculoskeletal
Neurological
Psychological
Fatigue, generalized weakness, weight loss, weight gain, abnormally thirsty
Visual difficulty, double vision, blurred vision, change of voice, difficulty
swallowing, painful swallowing
Neck pain, neck swelling
Fast heart rate, palpitations, chest pain, shortness of breath with exertion
Shortness of breath, cough, difficulty breathing when lying down, difficulty with
breathing when raising both arms above your head
Abdominal pain, nausea, vomiting, diarrhea, constipation
Frequent daytime urination, frequent nighttime urination, frequent urinary or
vaginal infections
For women: Last menstrual period _________, irregular periods, pregnant, post
menopausal (including surgical menopause)
For men: low libido, difficulty with erections, decreased shaving frequency
Dry skin, moist skin, rash, easy/excessive bruising, thin skin, excessive acne
For women only: male pattern hair growth
Prolonged bleeding, other blood disorders
Heat intolerance, cold intolerance
Poor muscle strength, previous fracture, osteoporosis, previous foot ulcer, calf
cramping
Burning/numbness/tingling of feet, tremors, jitteriness
Depression, anxiety
2
-------------------------------------------------------FOR STAFF USE ONLY------------------------------------------------------Physical Examination:
Pulse
Resting Rate
Blood Pressure
Height
Weight
BMI
Eyes: pupils equal round and reactive to light, injection, proptosis, lid lag, stare, icterus
HEENT: moist mucus membranes, no oral lesions,
Lymphadenopathy: Palpable abnormal lymph nodes: ant/post cervical, supra/infra clavicular
Neck: Thyromegaly _________, trachea deviated
Heart: irregular rate _______, irregular rhythm,
Chest: lungs clear to auscultation, negative Pemberton’s sign
Abdomen: soft, nontender, good bowel sounds,
Musculoskeletal: grossly intact muscle strength, no tenderness to palpation along spine/hips, intact
distance between pelvic brim and lower ribs
Extremities: no edema, palpable peripheral pulses, onychomycosis toenails
Neurological: 2 + DTRs, intact monofilament/vibratory sensation, alert, oriented
Skin: no ulcers on feet, dry skin, rash, jaundice
Psych: normal mood/affect, normal judgment
Other: ____________________________________________________________________________
Assessment/Plan:
Return to Clinic ___________________ Physician Signature: _________________________________
3