New Patient History
Patient Name
*
Patient Date of Birth
*
/
Month
/
Day
Year
Age
Sex
Male
Female
Reason for visit:
Past Medical History:
Please check YES if you have any of the following and include the YEAR of diagnosis:
Heart Attack
Yes
Year of Diagnosis
High Blood Pressure
Yes
Year of Diagnosis
High Cholesterol
Yes
Year of Diagnosis
Heart Disease
Yes
Year of Diagnosis
Heart Murmur
Yes
Year of Diagnosis
Rheumatic Fever
Yes
Year of Diagnosis
Scarlet Fever
Yes
Year of Diagnosis
Stroke
Yes
Year of Diagnosis
Tuberculosis
Yes
Year of Diagnosis
COPD
Yes
Year of Diagnosis
Asthma
Yes
Year of Diagnosis
Emphysema
Yes
Year of Diagnosis
Pneumonia
Yes
Year of Diagnosis
Thyroid Disease
Yes
Year of Diagnosis
IBS
Yes
Year of Diagnosis
Stomach Ulcer
Yes
Year of Diagnosis
GERD
Yes
Year of Diagnosis
Diverticulitis (osis)
Yes
Year of Diagnosis
Gallstones
Yes
Year of Diagnosis
Liver Disease
Yes
Year of Diagnosis
Kidney Disease
Yes
Year of Diagnosis
Kidney Stones
Yes
Year of Diagnosis
Pyelonephritis
Yes
Year of Diagnosis
STDs
Yes
Year of Diagnosis
Diabetes
Yes
Year of Diagnosis
Cancer
Yes
Year of Diagnosis
Anemia
Yes
Year of Diagnosis
HIV
Yes
Year of Diagnosis
Arthritis
Yes
Year of Diagnosis
Seizures
Yes
Year of Diagnosis
Depression
Yes
Year of Diagnosis
Anxiety
Yes
Year of Diagnosis
If you had or have cancer, please tell us the type and stage, what physician(s) treated you and what treatments you had:
Do you have any problems with hearing?
Do you have any problems with vision?
Please tell us if you are currently seeing any other physicians and who your previous medical doctor was:
Have you ever been hospitalized? Please list the reason, approximate date, and hospital:
Past Surgeries and Testing
Please check YES if you have had any of the following and include the YEAR(s)
Mastectomy
Yes
Year(s)
Hysterectomy
Yes
Year(s)
Knee Surgery (Right)
Yes
Year(s)
Knee Surgery (Left)
Yes
Year(s)
Hip Replacement (Right)
Yes
Year(s)
Hip Replacement (Left)
Yes
Year(s)
Hernia Repair
Yes
Year(s)
Back Surgery
Yes
Year(s)
Gallbladder Surgery
Yes
Year(s)
Appendectomy
Yes
Year(s)
Cataract Surgery (Right)
Yes
Year(s)
Cataract Surgery (Left)
Yes
Year(s)
Colonoscopy
Yes
Year(s)
Stool Test
Yes
Year(s)
Eye Exam
Yes
Year(s)
Foot Exam
Yes
Year(s)
Pap Test
Yes
Year(s)
Mammogram
Yes
Year(s)
PSA
Yes
Year(s)
Rectal Exam
Yes
Year(s)
Additional Testing
Please check YES if you have had the following and list the YEAR(s), LOCATION, and DOCTOR
Heart Catheterization
Yes
Year(s)
Location
Doctor
Angioplasty/Stent
Yes
Year(s)
Location
Doctor
Coronary Bypass
Yes
Year(s)
Location
Doctor
EKG
Yes
Year(s)
Location
Doctor
Stress Test
Yes
Year(s)
Location
Doctor
Echocardiogram
Yes
Year(s)
Location
Doctor
Chest X-Ray
Yes
Year(s)
Location
Doctor
Holter Monitor
Yes
Year(s)
Location
Doctor
Have you ever received a blood transfusion?
Yes
No
If yes, when and where?
Please list allergies and describe your reactions:
Current Medications
Please list all medications you currently take, including prescriptions, over the counter, herbals, and vitamins.
Medication #1
How Often Taken
Reason For Taking
Prescribing Doctor
Medication #2
How Often Taken
Reason For Taking
Prescribing Doctor
Medication #3
How Often Taken
Reason For Taking
Prescribing Doctor
Medication #4
How Often Taken
Reason For Taking
Prescribing Doctor
Medication #5
How Often Taken
Reason For Taking
Prescribing Doctor
Medication #6
How Often Taken
Reason For Taking
Prescribing Doctor
Medication #7
How Often Taken
Reason For Taking
Prescribing Doctor
Medication #8
How Often Taken
Reason For Taking
Prescribing Doctor
Medication #9
How Often Taken
Reason For Taking
Prescribing Doctor
Medication #10
How Often Taken
Reason For Taking
Prescribing Doctor
Medication #11
How Often Taken
Reason For Taking
Prescribing Doctor
Medication #12
How Often Taken
Reason For Taking
Prescribing Doctor
Medication #13
How Often Taken
Reason For Taking
Prescribing Doctor
Medication #14
How Often Taken
Reason For Taking
Prescribing Doctor
Pharmacy Name
Address
Phone Number
Format: (000) 000-0000.
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Employment Status
Full-Time
Part-Time
Retired
Student
Homemaker
Unemployed
What is your job title?
Where do you work/go to school?
Race
Ethnicity
Preferred language
Hand dominance
Right
Left
Ambidextrous
Religion
Church
Country of Birth
Social History
Marital Status
Single
Married
Divorced
Widowed
Separated
Do you have any children?
Yes
No
How many?
How many boys?
How many girls?
Do you have any pets?
Yes
No
How many?
What kind of pets do you have?
Have you ever been exposed to asbestos, glass, chemicals, or fumes?
Yes
No
Military History
Are you currently or have you ever served in the military?
Yes
No
What branch of the military?
How many years?
From what year
/
Month
/
Day
Year
To what year?
/
Month
/
Day
Year
Where were you stationed?
Recreational/Street Drugs/Steroid Use
Have you ever used recreational, street drugs, or illegal steroids?
Yes, currently
Yes, in the past
Never
If yes, what did/do you use?
Tobacco/Cigarettes
Age Started
Age Stopped
Method used to stop
Do you smoke?
Yes
No
Have you ever smoked?
Yes
No
If yes, when did you quit?
How many packs of cigarettes/cigars do you smoke per day?
How long have you been smoking?
Or, how long did you smoke before quitting?
Would you like to quit?
Yes
No
Have you tried to quit before?
Yes
No
Chewing Tobacco
Age Started
Age Stopped
Method used to stop
Do you chew tobacco?
Yes
No
Have you ever chewed tobacco?
Yes
No
If yes, when did you quit?
How many cans do you use per day?
How long have you been chewing tobacco?
Or, how long did you chew before quitting?
Would you like to quit?
Yes
No
Have you tried to quit before?
Yes
No
Vape Use
Do you vape?
Yes
No
Do you vape without nicotine?
Yes
No
Age started
Age stopped
Alcohol Use
Do you drink alcoholic beverages regularly (at least one drink per month)?
Yes, currently
No
Formerly
If you answered "yes" to any of the above questions, please complete the questions below.
Beer
Wine
Liquor
Have you ever quit drinking?
Yes
No
If yes, how old were you when you quit?
Exercise
Do you exercise regularly?
Yes
No
How many times per week?
What type/s of exercise?
Diet
Do you follow a special diet (i.e. diabetic, gluten free, low cholesterol)?
Yes
No
If yes, what type and why?
Caffeine
Type of caffeine:
Amount per day
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Living Will/Durable Power of Attorney for Health Care
**If you have one or both of these, please bring them in so we can keep them on file**
Do you have a Living Will?
Yes
No
Do you have a Durable Power of Attorney for Health Care?
Yes
No
If yes, please list the contact's name and phone number:
Immunizations
Please check if you have or have not had the following vaccines and the MONTH and YEAR it was given.
Flu Shot
Yes
No
Month/Year
Covid
Yes
No
Month/Year
Pneumovax
Yes
No
Month/Year
Tetanus
Yes
No
Month/Year
Zostavax
Yes
No
Month/Year
Hepatitis A
Yes
No
Month/Year
Hepatitis B
Yes
No
Month/Year
Gardasil (series)
Yes
No
Month/Year
Shingrix
Yes
No
Month/Year
Prevnar 13
Yes
No
Month/Year
HPV
Yes
No
Month/Year
Fall Risk
Do you use any of the following?
Walker
Cane
Wheelchair
Have you fallen in the last year?
Yes
No
Number of falls:
Did the fall/s result in injury?
Yes
No
If yes, please explain:
Family History
Do any of your relatives have the following? If yes, please let us know who: (Mother, Father, Brother/s, Sister/s, Maternal Grandparent/s, Paternal Grandparent/s, Children)
Diabetes
Yes
No
What relative/s?
High Cholesterol
Yes
No
What relative/s?
Seizures
Yes
No
What relative/s?
Blood Disorders
Yes
No
What relative/s?
Liver Disease
Yes
No
What relative/s?
Heart Disease
Yes
No
What relative/s?
High Blood Pressure
Yes
No
What relative/s?
Heart Attack
Yes
No
What relative/s?
Stroke
Yes
No
What relative/s?
Arthritis
Yes
No
What relative/s?
Kidney Disease
Yes
No
What relative/s?
Cancer
Yes
No
What relative/s?
Alchohol/Drug Abuse
Yes
No
What relative/s?
Depression/Anxiety
Yes
No
What relative/s?
If anyone in your family has died, how old were they when diagnosed; what was their age at death; and what was the cause of death?
Pain Assessment
Do you have pain on a daily basis?
Yes
No
Please rate your pain on the scale (with 10 being intolerable pain)
0
1
2
3
4
5
6
7
8
9
10
Other
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Review of Systems
Are you currently experiencing any of the following symptoms?
Constitutional
Recent weight change
Yes
No
Loss of appetite
Yes
No
Fatigue
Yes
No
Chills
Yes
No
Sweats/Hot flashes
Yes
No
Skin
Rashes
Yes
No
Itching
Yes
No
Abnormal moles
Yes
No
Head/Eyes/Ears/Nose/Throat/Neck
Chronic headaches
Yes
No
Migraines
Yes
No
Eye pain
Yes
No
Vision changes
Yes
No
Ear pain
Yes
No
Ear drainage
Yes
No
Hearing loss
Yes
No
Ringing in the ears
Yes
No
Nosebleeds
Yes
No
Nasal congestion
Yes
No
Nasal drainage
Yes
No
Recurrent throat infections
Yes
No
Hoarseness
Yes
No
Neck stiffness
Yes
No
Neck tenderness
Yes
No
Lymph nodes
Yes
No
Urinary
Burning
Yes
No
Blood in urine
Yes
No
Urgency
Yes
No
Frequent urination
Yes
No
Nighttime urination
Yes
No
Incontinence
Yes
No
Frequent urinary infections
Yes
No
*Females*
Vaginal discharge
Yes
No
Abnormal menses
Yes
No
Menopause
Yes
No
Postmenopausal bleeding
Yes
No
Age of 1st period
Last period
/
Month
/
Day
Year
# of pregnancies
# of births
# of abortions
Breast mass
Yes
No
Heart
Chest pain
Yes
No
Palpitations
Yes
No
Shortness of breath at rest
Yes
No
Shortness of breath with activity
Yes
No
Shortness of breath with laying
Yes
No
Swelling
Yes
No
Calf pain with walking
Yes
No
Lungs
Chronic cough
Yes
No
Sputum production
Yes
No
Cough up blood
Yes
No
Snoring
Yes
No
Gastrointestinal
Heartburn
Yes
No
Problems swallowing
Yes
No
Nausea
Yes
No
Vomiting
Yes
No
Diarrhea
Yes
No
Constipation
Yes
No
Abdominal pain
Yes
No
Blood in bowels
Yes
No
Blood in vomit
Yes
No
Jaundice/Yellowing of the skin
Yes
No
Hemorrhoids
Yes
No
Changes in bowels
Yes
No
Hematology/Oncology
Bruise easily
Yes
No
Prolonged bleeding
Yes
No
Musculoskeletal
Joint pain
Yes
No
Muscle pain
Yes
No
Arthritis pain
Yes
No
Numbness/tingling
Yes
No
Specific muscle weakness
Yes
No
Red, hot, swollen joints
Yes
No
Neurological/Psychological
Depression
Yes
No
Anxiety
Yes
No
Passing out
Yes
No
Dizziness
Yes
No
Seizures
Yes
No
Tremors
Yes
No
Insomnia
Yes
No
Poor memory
Yes
No
Endocrine
Excessive thirst
Yes
No
Excessive hunger
Yes
No
Excessive urination
Yes
No
Intolerance to heat
Yes
No
Intolerance to cold
Yes
No
Changes in nails
Yes
No
Hair loss
Yes
No
Q
K
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