New Patient History Form
Home Phone
Patient Last Name
Patient First Name
Patient Middle Initial
Responsible Party
Street Address
City
State
Zip
Sex
Male
Female
Age
Date of Birth
Single
Married
Widowed
Divorced
Separated
Soc. Sec. No.
Patient Employed By
Business Address
Occupation
Business Phone
Purpose Of Visit
Your primary care physician?
Physician Phone
Do you have medical insurance? Yes
No
If 'Yes',
Primary Insurance:
I.D.#:
Group #:
Secondary Insurance:
I.D.#:
Group #:
Insured's Name (if not patient)
Insured's SSN
Insured's DOB
Relationship to Patient
Spouse
Child
Self
Other
In case of emergency, who should be notified?
Relationship:
Phone Number:
Pharmacy Name:
Phone Number:
Confidential Health History
Symptoms
GENERAL
CHILLS
DEPRESSION
DIZZINESS
FAINTING
FEVER
FORGETFULLNESS
HEADACHE
LOSS OF SLEEP
LOSS OF WEIGHT
NERVOUSNESS
NUMBNESS
SWEATS
MUSCLE/JOINT/BONE
CHILLS
DEPRESSION
DIZZINESS
FAINTING
FEVER
FORGETFULLNESS
HEADACHE
LOSS OF SLEEP
LOSS OF WEIGHT
NERVOUSNESS
NUMBNESS
SWEATS
GENITO-URINARY
BLOOD IN URINE
FREQUENT URINATION
LACK OF BLADDER CONTROL
GASTROINTESTINAL
POOR APPETITE
BLOATING
BOWERL CHANGES
CONSTIPATION
DIARRHEA
EXCESSIVE HUNGER
EXCESSIVE THIRST
GAS
HEMORRHOIDS
INDIGESTION
NAUSEA
RECTAL BLEEDING
STOMACH PAIN
VOMITING
VOMITING BLOOD
OTHER
CARDIOVASCULAR
CHEST PAIN
HIG BLOOD PRESSURE
IRREGULAR HEART BEAT
LOW BLOOD PRESSURE
POOR CIRCULATION
RAPID HEART BEAT
SWELLING OF ANKLES
VERICOSE VEINS
EYE, EAR, NOSE, THROAT
BLEEDING GUMS
BLURRED VISION
CROSSED EYES
DIFFICULTY SWALLOWING
DOUBLE VISION
EARACHE
EAR DISCHARGE
HAY FEVER
HOARSENESS
LOSS OF HEARING
NOSEBLEEDS
PERSISTENT COUGH
RINGING IN EARS
SINUS PROBLEMS
VISION - FLASHES
VISION - HALOS
OTHER
SKIN
BRUISE EASILY
HIVES
ITCHING
CHANGING IN MOLES
RASH
SCARS
SORE THAT WON'T HEAL
MEN ONLY
BREASH LUMP
ERECTION DIFFICULTIES
LUMP IN TESTICLES
PENIS DISCHARGE
SORE ON PENIS
OTHER
WOMEN ONLY
ABNORMAL PAP SMEAR
BLEEDING BETWEEN PERIODS
BREAST LUMP
EXTREME MENSTRUAL PAIN
HOT FLASHES
NIPPLE DISCHARGE
PAINFUL INTERCOURSE
VAGINAL DISCHARGE
DATE/LAST MENSTRUAL PERIOD
DATE/LAST PAP SMEAR
HAVE YOU HAD A MAMMOGRAM?
DATE OF LAST BONE DENSITY
ARE YOU PREGNANT?
# CHILDREN
CONDITIONS: Check all that you have or have had in the past
AIDS
CHEMICAL DEPENDENCY
HIGH CHOLESTEROL
PROSTATE PROBLEM
ALCOHOLISM
CHICKEN POX
HIV POSITIVE
PSYCHIATRIC CARE
ANEMIA
DIABETES
KIDNEY DISEASE
RHEUMATIC FEVER
ANOREXIA
EMPHYSEMA
LIVER DISEASE
SCARLET FEVER
APPENDICITIS
EPILEPSY
MEASLES
STROKE
ARTHRITIS
GLAUCOMA
MIGRAINE HEADACHES
SUICIDE ATTEMPT
ASTHMA
GOITER
MISCARRIAGE
THYROID PROBLEMS
BLEEDING DISORDERS
GONORRHEA
MONONUCLEOSIS
TONSILITIS
BREAST LUMP
GOUT
MULTIPLE SCLEROSIS
TUBERCULOSIS
BRONCHITIS
HEART DISEASE
MUMPS
TYPHOID FEVER
BULIMIA
HEPATITIS
PACEMAKER
ULCERS
CANCER
HERNIA
PNEUMONIA
VAGINAL INFECTIONS
CATARACTS
HERPES
POLIO
VENEREAL DISEASE
MEDICATIONS: List all medications you are currently taking
LIST ALL ALLERGIES
FAMILY HISTORY - Fill in health information about your family
Relation
Age
Health
Age @ Death
Cause of Death
X
Check if any have or had the following
Father
Disease
Relationship to You
Mother
Arthritis, Gout
Brothers
Asthma, Hay Fever
Cancer
Chemical Dependency
Diabetes
Sisters
Heart Disease
strokes
High Blood Pressure
Kidney Disease
Year
Hospital
Reason
Outcome
Pregnancy History
Year
Sex of Child
Complications
Have you ever had a blood transfusion? Yes
No
Dates
Please describe serious illnesses / injuries you have had
Health Habits
Caffeine
Tobacco
Drugs
Other
Occupations Concerns
Stress
Hazardous Substances
Heavy Lifting
Other
Your Occupations Concern