Name________________________ History,
New Patient Health History
Today’s Date:
NAME_____________________________________________
1
___/___/______
Date of Birth ____/____/______
Address________________________________________________________________________
Current Phone Number(s) W__________________ H_______________ C_________________
Single
Married
Divorced
Widowed
Partnered // Live Alone__
With Others__
If you have children, please list their ages: ________________________
MEDICATIONS, VITAMINS, NUTRITIONAL SUPPLEMENTS
List name, dose, and number taken each day
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MEDICATION ALLERGIES or SENSITIVITIES (please describe briefly what happens)
___________________________________________________________________________
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OTHER ALLERGIES
_____________________________________________________________________________
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PAST MEDICAL PROBLEMS/SURGERY/HOSPITALIZATIONS
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Name________________________ History,
Have you had : Chicken Pox Y/N
Hepatitis
Mumps Y/N
Measles Y/N
Y/N (if yes, what kind?____)
When was your last: tetanus booster ____
flu shot____
2
German Measles Y/N
Tuberculosis
Y/N
pneumovax (pneumonia shot)_____
Have you had immunizations against (when): Measles/mumps/rubella ____
Hepatitis B____
Hepatitis A___
Polio____
FAMILY HISTORY:
Problem
Which
Relative(s)
At What Age(s)?
Depression________________________________________________________________________
Alchoholism________________________________________________________________________
Other Psychiatric____________________________________________________________________
Melanoma_________________________________________________________________________
Colon Cancer_______________________________________________________________________
Breast Cancer______________________________________________________________________
Ovarian Cancer_____________________________________________________________________
Prostate Cancer_____________________________________________________________________
Heart Attack/Coronary Artery Disease___________________________________________________
Diabetes__________________________________________________________________________
Osteoporosis_______________________________________________________________________
Dementia/Alzheimer’s________________________________________________________________
Other_____________________________________________________________________________
_________________________________________________________________________________
OTHER HISTORY
Ever smoked? No Yes
If Yes: How many packs/day________
How many years?___________
When did you quit?________
Smoking Currently? No Yes
If Yes: How much?________________
Do you drink Alcohol? No Yes
If Yes: How many drinks/day (average)___
If Yes:
Do you ever think you should cut down? Y
Do you ever feel guilty about drinking? Y
Do you get annoyed if others criticize
your drinking?
Y
Do you ever drink an “eyeopener”?
Y
N
N
N
N
Name________________________ History,
-Have you had sex in the last 3 months?
Yes
3
No
-How many sexual partners have you had in the last 5 years? _______
-Your sexual partner(s) are/have been
-Do you use contraception?
Yes / No
men____
women____
both_____?
If Yes, what?____________________________________
-Have you ever had a sexually transmitted disease? Yes /No
If Yes, what?_____________________
-Do you use protection against sexually transmitted disease? Yes/ No
-Have you ever used “recreational drugs”? yes/ no
-Have you ever had a blood transfusion? Yes/ No
-Do you exercise regularly? Yes / No
If Yes, what?_____________
If Yes, have you used needles?
Yes / No
When?________________
If Yes, What and How often?_________________________
-Do you drink 4 8-oz glasses of milk, or the equivalent, daily? Yes / No
Do you take calcium? Yes/ No
-When did you last see a dentist? _________________
eye doctor?__________________
-Please list the name and specialty of any other health care professionals you see:
_____________________________________
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_____________________________________
_____________________________________
_____________________________________
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Have you completed a Living Will or other Advance Directive?
Yes / No
If you were unable for some reason to make medical decisions for yourself, who would you want to
make those decisions for you? (for example, if you were unconscious after a bad auto accident, or had
had a major stroke)
Not Sure_________
(1) Name:___________________________
Relationship to you____________________
Address __________________________________________________
Phone number _________________________
Comments_________________________________________________________
__________________________________________________________________
Is this person aware that s/he would be responsible for decision making under such circumstances?
Y/ N
Name________________________ History,
PLEASE CHECK ANY OF THE FOLLOWING THAT APPLY TO YOU
Hayfever__
Decreased Hearing__
Nasal Congestion__
Hypothyroid__
Snoring__
Hyperthyroid__
Nose Bleeds__
glaucoma__
Goiter__
New weight gain___
New weight loss___
Unusual fatigue____
Diabetes___
Cough__
Wheezing__ Asthma__
Shortness of Breath__
Past Pneumonia__
Positive TB Skin Test__
Chest Pains__
Sleep Apnea__
Angina__
Palpitations__
Irregular Heart Beat__
New Fatigue or Shortness of Breath with Exercise__
Fainting__
Lightheadedness__
Leg Swelling__
Heartburn__
Abdominal Pain__
Swallowing difficulty__
Nausea__
Vomiting__ Constipation__ Diarrhea__
Black BM ___
Rectal Bleeding ___
Irritable Bowel__
Inflammatory Bowel Disease__
Gall Bladder Problems__
Stomach bleeding__
Ulcers__
Hepatitis__ Hernia__
Burning or Pain with urination__
Night time urination__
Difficulty urinating__
Incontinence__
Increased Frequency of urination___
Bladder infections__
Kidney stones__
Kidney Infections__
Blood in the Urine__
Joint pain__ Hot/Swollen Joints__ Joint Injury__
Gout__
Osteoarthritis__
Muscle pain__
Fractured Bones__
Osteoporosis__
Clinician’s Notes
4
Name________________________ History,
Lyme Disease__
Skin Cancers__
Back Pain__
sciatica__
5
Clinician’s Notes:
Eczema__ Hives__ Acne__
Cold Sores__ Genital Herpes__ Psoriasis__
Headaches__
Numbness or Tingling__
Weakness or paralysis__
History of stroke__
Vision changes__
History of meningitis__
Difficulty walking___
Tremor__
Balance problems___
Unusual Bruising/bleeding__ Blood Clots __
Phlebitis__ Anemia__ Swollen Glands___
Sad Mood__
Difficulty Sleeping__ Anxiousness__
Suicidal Thoughts__
Inability to enjoy activities__
History of Abuse__
History of treatment for emotional problems____
Sexual function concerns___
MEN ONLY
Prostatitis__
Discharge from Penis__
Problems with erections__
Pain or lump in testicles/scrotum___
WOMEN ONLY
Periods started at (what age)_____
If No, at what age did your periods end? ____
Pregnancies Y/N (How many)____
Have you had a hysterectomy?
Live Births Y/N
If yes, were your ovaries also removed? Y/N
(How many)_____
Abnormal Pap smears? Y/N
If yes, when was the last one?______
Y/N
If you no longer get periods, skip the following
questions.
Vaginal spotting __
Last Menstrual Period (when)_____
Abnormal vaginal discharge__
Bleeding between periods ___ Heavy periods ___
Do you still get a period? Y/N
Painful periods____
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Please list any other symptoms or concerns that you want to make us aware of at this visit
(if we cannot address them all today, we will arrange to see you again very soon)
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Name________________________ History,
6