NEW PATIENT HISTORY
Name: ____________________________________ Date of Birth: _________________ Age: __________
Reason for today’s visit: ________________________________________________ Date: ____________
Medical History (High Blood Pressure, Diabetes, Asthma, Cancer, Heart Disease, etc)
Menstrual History
None
Pregnancy History
Age at first menstruation
Duration of bleeding (days)
Number of tampons/pads a day
Date of last normal period
Number of days from the start of
one period to the start of the next
Premenstrual Symptoms?
Severe Cramps?
Hot Flashes?
________________
________________
________________
________________
________________
________________
________________
________________
Do you think you are pregnant?
Number of pregnancies (including current)
Number of full term pregnancies
Number of living children
Any complications with pregnancies
or deliveries?
____Y ____N
__________
__________
__________
____Y ____N
Gynecological History
What are you currently doing, if anything, to prevent pregnancy?
Have you ever used birth control pills?
Any complications with the pill?
Have you ever had an abnormal pap smear?
__________________________________________
____Y ____N
____Y ____N
____Y ____N
Surgical History (Tonsillectomy, Appendectomy, Gall Bladder, Hysterectomy, etc)
Allergies to Medications?
stomach, etc)
None
None (If yes, please explain type of reaction i.e. hives, wheezing, upset
Current Prescription Medicines
Name of Drug /mg dose /# tablets /#times per day
Current Prescription Medicines
Name of Drug /mg dose /# tablets /# times per day
Over the counter medicines (Aspirin, Tylenol, Ibuprofen, Aleve, vitamins, herbals, etc)
NEW PATIENT HISTORY
Name: ______________________________________________________ Date: _____________
Family History
Father:
Mother:
Siblings:
Living Age: ___
Living Age: ___
Living Age: ___
Deceased, Age at Death: ___
Deceased, Age at Death: ___
Deceased, Age at Death: ___
Cause: ____________________
Cause: ____________________
Cause: ____________________
List other illnesses in your family: (Example: Diabetes, Heart Disease, Hypertension, Cancer, etc)
Family Member Illness
Family Member Illness
Family Member Illness
Social History
Smoke?
No Yes If yes, how much? ____# packs/day ____ # of years. When did you stop smoking? ________
Alcohol? No Yes If yes, how much? ___________________ History of Substance Abuse? No
Yes
Occupation: ____________________________ Marital Status (circle) Married Single Widowed Divorced
Exercise routinely? No
Yes If yes, what and how frequently? ______________________________________
Review of Symptoms
Are you currently or have you in the past experienced any of the following symptoms?
Constitutional Symptoms
Comments Urinary
Comments
Weight change
Chills
Sleep Disorder
Other
Y N
Y N
Y N
Eyes
Double Vision
Glaucoma
Cataracts
Other
Involuntary loss of urine
Urinary frequency
Urinary pain
Blood in urine
Other
N
N
N
N
Genital
Y N
Y N
Y N
Frequent infections
Painful intercourse
Abnormal bleeding
Other
Ears/Nose/Throat/Mouth
Sexual
Hearing changes
Sore throat
Sinus problems
Other
Change in sex drive
Multiple partners
STD exposure
Other
Y N
Y N
Y N
Cardiovascular
Chest pain
Irregular heart beat
Swelling in ankles
Other
Y
Y
Y
Y
Y N
Y N
Y N
Y N
Y N
Y N
Musculoskeletal
Y N
Y N
Y N
Bone pain
Joint pain
Muscle pain
Other
Y N
Y N
Y N
NEW PATIENT HISTORY
Name: ______________________________________________________ Date: _____________
Psychological
Are you generally happy?
Do you feel depressed
Do you feel anxious?
Other
Comments
Y N
Y N
Y N
Endocrine
Excessive thirst
Too hot/cold
Tired/sluggish
Other
Y N
Y N
Y N
Comments
Y
Y
Y
Y
N
N
N
N
Tremors
Dizzy spells
Seizures
Other
Y N
Y N
Y N
Respiratory
Y N
Y N
Y N
Allergic/Immunologic
Hay fever
Drug allergies
Food allergies
Other
Rash
Lumps or Bumps
Moles, skin tags
Varicose veins
Other
Neurological
Hematologic
Swollen glands
Blood clotting problems
Bruising
Other
Skin
Wheezing
Frequent cough
Shortness of breath
Other
Y N
Y N
Y N
Gastrointestinal
Y N
Y N
Y N
Abdominal pain
Nausea/vomiting
Indigestion/heartburn
Other
Y N
Y N
Y N
Physician/provider signature: _________________________________________ Date: _______
Reviewed/Updated:_____________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________