Asheville Medicine and Pediatrics
New Patient Medical History
Please fill out all sections completely.
PATIENT NAME: _________________________________________ DATE OF BIRTH: __________________________
Please list ALL medications you are currently taking. Be sure to include strength and directions for use.
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Are you allergic to any medication(s)?
YES
NO
If so, please list the medication and reaction: ___________________________________________________________
Please tell us about your medical history by checking the box beside any illness or condition that you have or have had in the past.
CARDIOVASCULAR
__ AORTIC ANEURISM
__ CORONARY HEART DISEASE
__ HIGH BLOOD PRESSURE
__ VALVE PROBLEMS
__
__
__
__
PULMONARY
__ ASTHMA
__ PNEUMONIA
__ SLEEP APNEA
__ CHRONIC BRONCHITIS
__ PULMONARY EMBOLISM
__ TUBERCULOSIS
__ COPD/EMPHYSEMA
__ PULMONARY HYPERTENSION
__ OTHER: ____________________
GASTROINTESTINAL
__ CIRRHOSIS
__ HEARTBURN/GERD
__ PANCREATITIS
__ COLON POLYPS
__ HEPATITIS
__ PEPTIC ULCER DISEASE
__ CROHN’S DISEASE
__ IRRITABLE BOWEL SYNDROME
__ OTHER: ____________________
GENITOURINARY
__ RENAL FAILURE
__ DIFFICULTY URINATING
__ INCONTINENCE
__ ENLARGED PROSTATE
__ ERECTILE DYSFUNCTION
__ URINARY TRACT INFECTIONS
__ ENDOMETRIOSIS
__ KIDNEY STONES
__ OTHER: _____________________
MUSCULOSKELETAL
__ CHRONIC PAIN
__ GOUT
__OSTEOPOROSIS
__FIBROMYALGIA
__HIP REPLACEMENT
__ RHEUMATOID ARTHRITIS
__ BROKEN BONES: ___________
__ OSTEOARTHRITIS
__ OTHER: _____________________
ENDOCRINE/METABOLIC
__ DIABETES TYPE ONE
__ HYPERTHYROIDISM
__ DIABETES TYPE TWO
__ HYPOTHYROIDISM
__DYSMETABOLIC SYNDROME
__ OTHER: ______________________
___NEUROLOGICAL
__ ALZHEIMER’S DISEASE
__ MIGRAINE HEADACHES
__ PARKINSON’S DISEASE
__ADD/ADHD
__ TENSION HEADACHES
__ PERIPHERAL SENSORY NEUROPATHY
__ STROKE
__ TRANSIENT ISCEMIC ATTACK
__OTHER: ________________________
BLOOD DISORDERS
__ ANEMIA(PERNICIOS/IRON DEFF)
__ SICKLE CELL ANEMIA
__OTHER: ________________________
ALLERGY/DERMATOLOGY/OTHER
__ ALLERGIES
__RECURRENT SINUS INFECTIONS
__ ECZEMA
__INSOMNIA
__RECURRENT EAR INFECTIONS
__OTHER: ________________________
ARRHYTHMIA
DEEP VEIN THROMBOSIS
HEART ATTACK
HEART MURMUR
__
__
__
__
CONGESTIVE HEART FAILURE
HIGH CHOLESTEROL
PACEMAKER
OTHER: ____________________
Do you have any history of CANCER?
YES
NO
Where/What kind? ______________________________________________________ When? ______________________
Do you have any Vision impairment? YES
__
CATARACTS
__GLAUCOMA
NO
__MACULAR DEGENERATION
__ Blind
__OTHER ____________________
Do you have any Hearing impairment or are you deaf? YES
NO
If Yes, please describe and advise if you need any special communication assistance?
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Revised 4/11/2014
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PATIENT NAME: _________________________________________ DATE OF BIRTH: __________________________
Please tell us about your medical history by checking the box beside any illness or condition that you have or have had in the past.
All Adults and Adolescents between the ages of 12-18
Over the past two weeks, how often have you been bothered by any of the followings problems? (Please circle your
answers)
Little interest or pleasure doing things?
0=Not at all
1=Several days
2= More than half the days
3= Nearly every day
Feeling down, depressed or hopeless
0=Not at all
1=Several days
2= More than half the days
3= Nearly every day
Do you have Advance Care Planning? Yes or No If yes-please provide a copy, If no, do you want to discuss this with
your physician today?
FOR WOMEN:
____ AGE OF MENSES
__ ENDOMITRIOSIS
____IRREGULAR/HEAVY MENSTRUATION
__ HYSTERECTOMY
___MENOPAUSE _____ AGE
__ OTHER FEMALE PROBLEMS _______________________________________
_____________________ DATE OF LAST BONE DENSITY
________________________ DATE OF LAST MAMMOGRAM
HOW MANY Pregnancies? _______ Vaginal Births? ________ C-sections __________ Elective Abortions? _______ Miscarriages _______
Do you use birth control?
YES
No
When was your last PAP? ____________________________
If yes, what kind/method? __________________________________________
Any abnormality? ___________________________________________________
Please list any SURGERIES you have had and the dates they were performed.
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Additional Procedures: __ Colonoscopy (Date) ______________
__ Echocardiogram (Date) ____________________
__ Stress Tests (Date) _______________________
Family History: Please check all that apply and choose from the listed relations below to show history.
M- mother, F- father, S- sister, B- brother, Son- son, d- daughter, MGM-maternal grandmother
MGF- maternal grandfather, PGM- paternal grandmother, PGF- paternal grandfather
__ HIGH BLOOD PRESSURE _____
__ ENLARGED PROSTATE _____
__ FIBROMYALGIA
_____
__ HIGH CHOLESTEROL
_____
__ KIDNEY STONES
_____
__ OSTEOARTHRITIS
_____
__ HEART ATTACK
_____
__ ALZHEIMER’S
_____
__ OSTEOPOROSIS
_____
__ CANCER (WHAT TYPE)
_____
__ STROKE
_____
__ ALCOHOLISM
_____
__ ASTHMA
_____
__ MIGRAINES
_____
__ ANXIETY
_____
__ COPD/EMPHYSEMA
_____
__ SEIZURE DISORDER
_____
__ DEPRESSION
_____
__ CIRRHOSIS
_____
__ TIA’s
_____
__ GLAUCOMA
_____
__ IRRITABLE BOWEL(IBS) _____
__ DIABETES TYPE 1
_____
__ CATARACTS
_____
__ PANCREATITIS
_____
__ DIABETES TYPE 2
_____
__ OTHER _________________
__ HYPERTHYROIDISM
_____
__ HYPOTHYROIDISM
_____
ADULT VACCINES
__
TDAP (Date)
__________ __
Pneumonia (Date)
____________ __Flu (Date) ____________ __
Shingles(Date)
__________
Please list all VITAMINS OR DIETARY SUPPLEMENTS you use. Be sure to include strength and directions for use.
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Revised 4/11/2014
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Please circle “yes” or “no” to each question or check all applicable answers.
Social History:
Are you Employed?
Are you Married?
Yes
No
Single
Do you have any children?
Retired? What was your occupation?
Widowed
Divorced
Yes No
If so, how many?
Do you smoke or use tobacco? Yes Nonsmoker
Did you quit smoking? Yes When?
Do you drink alcohol? Yes No
If so, how much/often?
If not, are you interested in quitting? Yes
No
If so, how much and how often
Do you suffer from any Mental or Emotional Disorders?
__ANXIETY
__EATING DISORDER
__DEPRESSION
__BIPOLAR DISORDER
__OBSESSIVE-COMPLUSIVE DISORDER
__OTHER
Please answer all questions below.
PEDIATRICS:
Parent’s Marital Status:
Married
Single
Separated
Divorced
Family members living in household:
Mother’s Occupation:
Father’s Occupation:
Is the child exposed to smoke in the home?
Yes No
Name of school child attends.
Grade:
Teams/Clubs:
Revised 4/11/2014
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