NEW PATIENT INFORMATION NAME:______________________________ DOB:_______________
1.
What is the reason for your visit? Please list symptoms & duration:
________________________________________________________________________________
2.
Are you in any pain? Yes____ No ____ Where?_____________ What relieves it?_______________
3.
Please rate your pain: No Pain - 0 1 2 3 4 5 6 7 8 9 10 - Extremely Painful
4.
Who referred you to our practice? ___________________________________________________
5.
Who is your Primary Care Physician? _________________________________________________
6.
Please list any drug or food allergies. What is your reaction?
________________________________________________________________________________
________________________________________________________________________________
7.
Any latex allergies? Yes ___ No ___ Allergies to IODINE? Yes ___ No ___ Seafood? Yes ___ No ___
8.
Do you have a pacemaker? Yes ___ No ___ If Yes, Manufacturer ___________________________
9.
Have you ever had a colonoscopy or upper endoscopy? Yes___ No____ Date __________________
Name of Doctor_____________________ Results________________________________________
10.
List your current medications. Name, Strength, How often you take the medication.
Include Over the Counter, Herbal supplements, & Vitamins.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
11.
Do you take aspirin and/or blood thinners? Yes ___ No ___ Type and dose ___________________
12.
Preferred Pharmacy: ______________________________________________________________
13.
Any unexplained weight loss or weight gain? Yes ___ No ___ Amount of Loss/Gain ____________
14.
Do you have trouble sleeping? Yes ___ No ___ Do you take any sleep aids? Yes ___ No ____
PERSONAL HISTORY
1.
Marital Status ________ Current Occupation/Employer_______________________________
2.
Education______________________________ Ethnicity ____________________________
3.
Primary language________________________ Religion_____________________________
4.
Do you use tobacco? Yes ___ No ___If yes, when did you start _______Quit? _______
5.
Does anyone around you smoke? Yes ___ No ___
6.
Do you drink alcohol? Yes ___ No ___ If yes, How many? Per Week___ Per Mo.___
7.
Do you use illicit drugs? Yes ___ No ___ If yes, what type? ______________________________
8.
How many caffeinated drinks per day do you have? _______ Type ________________________
9.
How many times a week do you exercise? ______ Type of exercise _______________________
10.
(For Women) Last Menstrual Period ______________ Are you pregnant? Yes_____ No _______
Please complete the back of this form.

Medical history: Please indicate chronic conditions or if you are currently experiencing:
CONSTITUTIONAL:
 Change in activity
 Change in appetite
 Chills
 Night sweats
HENT:
 Hearing loss
 Sinus problems
 Dental problems
 Dentures/Partials
EYES:
 Visual changes
 Fatigue
 Fever
 Unexpected weight change
 Mouth sores
 Sore throat
 Trouble swallowing
 Voice change
 Eye problems
RESPIRATORY:
 Sleep Apnea
 CPAP machine use
 Cough
 Shortness of breath
 Wheezing
 Asthma
CARDIOVASCULAR:
 Chest pain
 Leg swelling
 Heart disease
 Defibrillator/Pacemaker
 Palpitations  Heart murmur
 High blood pressure  Heart surgery
GASTROINTESTINAL:
 Poor appetite  Constipation
 Difficulty swallowing  Diarrhea
 Heartburn/Indigestion  Nausea/Vomiting
 Acid Reflux  Rectal pain
 Ulcer
 Abdominal bloating
 Abdominal pain
 Rectal bleeding
 Blood in stool



Hemorrhoids
Rectal soiling/leakage
Liver problems
 Colon/stomach polyps
 Hernia
ENDOCRINE:
 Diabetes
 Thyroid problems
 Hypoglycemia
GENITOURINARY:
 Painful urination
 Bloody urine
 Kidney problems
 Frequent urination
 Genital lesions
MUSCULOSKELETAL:
 Joint pain
 Back pain
 Muscle weakness
 Muscle pain
SKIN:
 Rashes
 Lesions or wounds
 Skin problems
 Jaundice
NEUROLOGIC:
 Headaches
 Numbness
 Seizures
HEMATOLOGIC:
 Bleeding problems
 Bruises easily
 Loss of consciousness
 Weakness
 Stroke
 Enlarged lymph nodes
 Anemia/Low blood count
PSYCHIATRIC:
 Depression
 Anxiety
 Mental disturbance
 Sleep disturbance
INFECTIONS:
 Hepatitis (Type:___)  Tuberclosis (TB)
 HIV
 MRSA


AIDS
Stool C-Diff
Do you have a history of cancer? Yes ___ No ___
Type:________________________________________
Please list any surgeries:
_____________________________________________
_____________________________________________
_____________________________________________
Have you ever had any problems with anesthesia?
Yes ______ No ______
Medical Problems:(i.e. Diabetes, High Blood Pressure):
_____________________________________________
_____________________________________________
_____________________________________________
Family History
Mother:
Living ___ Deceased ___ Illness___________________
Father:
Living ___ Deceased ___ Illness___________________
Sisters: How many? _____
Living ___ Deceased ___ Illness___________________
Brothers: How many? ____
Living ___ Deceased ___ Illness___________________
Children: How many?_____
Living ___ Deceased ___ Illness___________________
Does anyone in your family have a history of cancer, bowel disease, or autoimmune illness?
_____________________________________________
_____________________________________________
Thank you for taking the time to complete this form.