RIVERWOOD FAMILY MEDICINE
NEW PATIENT-MEDICAL HISTORY FORM
Please complete this form and bring it to your appointment. You may also mail it back to the
office prior to your appointment date.
Date: _____________________
Full-legal name___________________________________
Date of Birth: ____________________________________
Allergies or drug reactions (list drug and reaction):
Please list the conditions you are currently being treated for:
Please list any other doctors who are also currently treating you:
Past medical history (Please list all hospitalizations, major illnesses and surgeries):
Event
Date of Occurrence
1
Who lives in your home with you? (Spouse, children, in-laws, significant others, etc.)
Your occupation:
Do you get regular exercise? (Describe)
Do you wear seatbelts?
Always
Usually
Occasionally
Never
Smoking history: (please check)
____ never smoked ____previous smoker x ____years; quit _____ (when?)
____current smoker x ______years; _____ packs per day
Do you use other forms of tobacco such as chewing tobacco, pipe, cigars?
If yes, how often?
Alcohol Screen:
Do you drink beverages that contain alcohol?
How often do you have alcoholic beverages?
1/month
More than 1/week
Have you ever had a drinking problem?
1/week
More than 1/month
How many cups of coffee or caffeinated drinks do you drink daily?
Do you use marijuana, cocaine, any street drugs or prescription drugs that were not prescribed
for you?
Family History:
Age, if
living
Mother
Age at
death
Health problems or cause of death
Father
Siblings
Children
2
Medications: (Please list all the medication you are taking, including over-the-counter
medications, vitamins, herbs and other treatments.)
Name of
Prescribed by
Dosage When is the
Purpose
Will you be in
medication
medication taken
need of refills
at your visit?
Vaccinations:
Vaccine
Tetanus (Td, TdaP, Dtap, Tetanus Toxoid)
Influenza
Pneumonia
Hepatitis B
Shingles (Zostavax)
Others (please list)
Date of last one
3
History of Tests/Exams:
Exam
Colonoscopy
Bone Density
Mammogram
Pap Smear
PSA
Eye exam
Others (please List)
Date last completed
Check whether or not you have or have had these conditions:
Yes
Fatigue
Fever or chills
Recent weight change
Headache
Vision changes
Eye itching
Eye pain
Ringing in ears
Runny nose
Nose bleeds
Nasal congestion
Snoring
Hoarseness
Sore throat
Mouth sores
Breast lump or pain
Chest pain
Irregular heart beat
Pounding heart beat
Shortness of breath
Cough
Wheezing
Decreased appetite
Difficulty swallowing
Heartburn
Nausea
4
No
Vomiting
Abdominal pain
Black tarry stools
Rectal bleeding
Diarrhea
Constipation
Blood in urine
Urinating too often
Pain with urination
Excessive thirst
Weakness
Easy bruising
Muscle aches
Joint pain or stiffness
Swelling in arms or legs
Dizziness
Fainting
Memory problems
Numbness
Anxiety
Depression
Trouble sleeping
Hallucinations
Dry skin
Itching
Lump or spot on skin
Rash
Stress
Other (please list)
Do you have any specific concerns for your first visit? (Describe)
5