Name: ________________________________________________
Date of Birth: _______________________________________
History and Intake Form
Past Medical History: (please circle all that apply)
Anxiety
Hepatitis
Arthritis
Hypertension
Artificial joints
HIV/AIDS
Asthma
Hypercholesterolemia
Atrial fibrillation
Hyperthyroidism
BPH
Hypothyroidism
Bone Marrow Transplantation
Leukemia
Breast Cancer
Lung Cancer
Colon Cancer
Lymphoma
COPD
Pacemaker
Coronary Artery Disease
Prostate Cancer
Depression
Radiation Treatment
Diabetes
Seizures
End Stage Renal Disease
Stroke
GERD
Valve Replacement
Hearing Loss
None
Other _________________________________________________________________________________________
Past Surgical History: (please circle all that apply)
Appendix Removed
Kidney Biopsy
Bladder Removed
Kidney Removed (Right, Left)
Mastectomy (Right, Left, Bilateral)
Kidney Stone Removal
Lumpectomy (Right, Left, Bilateral)
Kidney Transplant
Breast Biopsy (Right, Left, Bilateral)
Ovaries Removed: Endometriosis
Breast Reduction
Ovaries Removed: Cyst
Breast Implants
Ovaries Removed: Ovarian Cancer
Colectomy: Colon Cancer Resection
Prostate Removed: Prostate Cancer
Colectomy: Diverticulitis
Prostate Biopsy
Colectomy: IBD
TURP
Gallbladder Removed
Skin Biopsy
Coronary Artery Bypass
Basal Cell Cancer Surgery
PTCA
Squamous Cell Carcinoma Surgery
Mechanical Valve Replacement
Melanoma Surgery
Biological Valve Replacement
Spleen Removed
Heart Transplant
Testicles Removed (Right, Left,
Joint Replacement, Knee (Right, Left,
Bilateral)
Bilateral)
Hysterectomy: Fibroids
Joint Replacement, Hip (Right, Left,
Hysterectomy: Uterine Cancer
Bilateral)
None
Joint Replacement within last 2 years
Other _________________________________________________________________________________________
Name: ________________________________________________
Date of Birth: _______________________________________
Skin Disease History: (please circle all that apply)
Acne
Hay Fever/Allergies
Actinic Keratoses
Melanoma
Asthma
Poison Ivy
Basal Cell Skin Cancer
Precancerous Moles
Blistering Sunburns
Psoriasis
Dry Skin
Squamous Cell Skin Cancer
Eczema
None
Flaking or Itchy Scalp
Other ________________________________________________________________________________________
Do you wear Sunscreen?
Yes
If yes, what SPF? ___________
Do you tan in a tanning salon?
No
Yes
No
Do you have a family history of Melanoma?
Yes
No
If yes, which relative(s)? ___________________________________________________________________
Any other family history: __________________________________________________________________
Medications: (Please enter all current medications)
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Allergies: (Please enter all allergies)
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Preferred Language: English _______________
Other: _______________
Some diseases are more prevalent in certain racial and ethnic groups, therefore we
would appreciate it if you would specify your race and ethnicity.
Race (please check or circle):
_____ Caucasian
_____ African American
_____ American Indian
_____ Asian
____ Other (please specify): ______________
Ethnicity: ________ Hispanic or Latino
________ Not Hispanic or Latino
Name: ________________________________________________
Date of Birth: _______________________________________
Social History: (Please circle all that apply)
Cigarette Smoking:
Never smoked
Quit: former smoker
Smokes less than daily
Smokes daily
Sexual History:
Not sexually active
Sexually active with one partner
Sexually active with more than one partner
Same sex partner
Illicit Drug Use:
Drug Use
IV Drug Use
Alcohol Use:
Alcohol: none
Alcohol: less than 1 drink a day
Alcohol: 1-2 drinks a day
Alcohol: 3 or more drinks a day
Safety:
I feel safe at home.
I do not feel safe at home.
Other_________________________________________________________________________________________
None
Name: ________________________________________________
Date of Birth: _______________________________________
Are you currently experiencing any of the following?
(please check yes or no for the following)
Symptom
Allergy to lidocaine
Rapid heart beat with epinephrine
Allergy to topical ointments
Allergy to adhesive
Blood thinners
Artificial joints within past two years
Artificial heart valve
Premedication prior to procedures
Problems with bleeding
Problems with healing
Problems with scarring (hypertrophic or keloid)
Yeast infection with antibiotics
GI upset with antibiotics
Thyroid problems
Joint aches
Muscle weakness
Neck stiffness
Sore throat
Fevers or chills
Night sweats
Unintentional weight loss
Abdominal pain
Bloody stool
Bloody urine
Yes
No
Other Symptoms: ___________________________________________________________________________
Name: ________________________________________________
Date of Birth: _______________________________________
Alerts: Are you currently experiencing any of the following?
(please check yes or no for the following)
Alert
Chest pain
Pace maker
defibrillator
Shortness of breath
wheezing
cough
headache
Blurry vision
seizures
depression
anxiety
immunosuppression
Hay fever
rash
Changing mole
Pregnancy or planning a pregnancy
Any other health concern we should know
about
Yes
No
Other Symptoms: ___________________________________________________________________________
Name: _____________________________________________
Date of Birth: ____________________________________
Pharmacy and Doctor Information
Pharmacy
Name: _________________________________________________
Address: _______________________________________________
________________________________________________
Telephone Number: _____________________________________
Primary Care Physician
Name: _________________________________________________
Address: _______________________________________________
________________________________________________
Telephone Number: _____________________________________
Please list other physicians to whom we need to send records:
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
Theta S. Pattison, MD
2508 Western Avenue
Altamont, NY 12009
Telephone: 518-690-0177
Fax: 518-690-0169
HIPAA Communication Authorization
Permission to communicate protected health information
HIPAA limits healthcare organizations as to who they may communicate with regarding
your care and how they may communicate. In order to help us communicate about your
care as you want and with whomever you want, we ask that you complete this form.
Please provide us with the names of those individuals who are involved with your care and
with whom we may share your protected health information. I authorize Theta S.
Pattison, MD and employees, using their best judgment, to discuss my healthcare and my
protected health information with the following individuals in order to facilitate and
coordinate my care:
____________________________________________________________________________________________________
Name of Individual
Relationship to Patient
Telephone Number
____________________________________________________________________________________________________
Name of Individual
Relationship to Patient
Telephone Number
____________________________________________________________________________________________________
Name of Individual
Relationship to Patient
Telephone Number
____________________________________________________________________________________________________
Name of Individual
Relationship to Patient
Telephone Number
We also would like to be able to leave telephone messages containing protected health care
information for you, if you are willing to let us do so. I authorize Theta S. Pattison, MD
and employees to leave messages containing protected healthcare information at the
following telephone number(s): ________________________________________________________ .
Patient’s Name (print): _________________________ Date of Birth: ____/____/____
Signed: ________________________________ Date: __________________
If Signed by someone other than the patient, please specify
your authority to act for patient: ______________________