PrimeCarePartners
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NEW PATIENT
PERSONAL MEDICAL HISTORY
I have a personal history of the following problems:
Arthritis: what type?
Blood Disorder: what
kind?
Cancer: what kind?
Diabetes
Ears/Nose/Throat:
specify
Gastrointestinal: what
type?
Genitourinary/Prostate
Heart Problems
High Blood Pressure
High Cholesterol
Kidney Problems
Liver Problems, Hepatitis
Lung Problems/asthma
Musculoskeletal problems
Neurology: Stroke/Seizures
Psychiatric problems
Sexually Transmitted Diseases
Thyroid abnormality
other:
I have had the following surgeries:
If you have had surgery on one or more of these body areas, indicate what type of surgery:
□ Head/Neck/Breast surgery:
□ Abdominal/Pelvic surgery: __
□ Heart/Lung surgery:
_______
□ Bone/Joint surgery:
□ Spine Surgery:
□ other:
Medications:
Occupation & Employer:
Circle Current Marital Status
Circle Current Living Situation
Single
Partner
Married
Husband
Partnered
Wife
Separated Divorced
Alone
Roommate
Widowed
Parent
Family History: Indicate Which Family Member(s) M=Mom D=Dad C=Child S=Sibling A= Aunt U=Uncle GP=Grandparent
Cardiovascular
Diabetes
Disease
High Cholesterol
Alzheimer’s disease
Cancer/Leukemia
Psychiatric
High Blood Pressure
Stroke/CVA/TIA/Seizures
Lung Disease
Liver disease
Brain Aneurysm
Other:
I certify that the above information is accurate:
_ Date:_________________
Patient’s signature (or patient’s representative)
PCP New Patient Med history, Rev. 11/2013
Please See Backside →
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I have had the following procedures:
Test
Colonoscopy
Hemoccult (test for blood in stool)
Mammogram
DEXA (bone density test for osteoporosis)
Cholesterol blood test
Diabetes blood test
Men only: PSA (prostate blood test)
Men only: AAA screen (abdominal aorta ultrasound)
Women only: Pap smear
Date or Year
Results (normal/abnormal)
I have had the following Vaccines:
Vaccine
Tetanus
Pertussis
Influenza (flu)
Pneumonia
Hepatitis A
Hepatitis B
Meningitis
HPV
shingles
Date/Year Administered
These are the specialists currently involved in my care (if any):
Opthalmologist:_____________________________________________________________________________________
Cardiologist:________________________________________________________________________________________
Pulmonologist:______________________________________________________________________________________
Dermatologist:______________________________________________________________________________________
Oncologist:_________________________________________________________________________________________
Orthopedist:________________________________________________________________________________________
Ear/Nose/Throat:____________________________________________________________________________________
Urologist:__________________________________________________________________________________________
Neurologist:________________________________________________________________________________________
Gynecologist:_______________________________________________________________________________________
Gastroenterologist:__________________________________________________________________________________
For Women only:
Have you ever had an abnormal Pap smear? Yes_____ No_____ If so, when and what (if any) procedures were
done?____________________________________________________________________________________________
Have you ever had an abnormal mammogram? Yes_____ No_____ If so, when and what (if any) procedures were
done?____________________________________________________________________________________________
Have you had a hysterectomy? Yes_____ No_____ If so, what was the reason?_________________________________________
Are you still menstruating? Yes_____ No_____ If no, how old were you when you stopped?__________________________
I certify that the above information is accurate:______
_________
Date:________________
Patient’s signature (or patient’s representative)
PCP New Patient Med history, Rev. 11/2013