New Patient

Medical History Form

Name:__________________________________ Date of Birth:_________ Today’s Date:___________

Reason you are here:_________________________________________________________________

Personal Medical History: Have you ever had any of the following conditions? (Check if yes)

Anemia Crohn’s Disease HIV/ AIDS

Arthritis Depression Hypertension
Asthma Diabetes Kidney Disease
Cancer Emphysema Myocardial Infarction
Chronic Obstructive Pulmonary Endocrine Problems Peptic Ulcer Disease
Disease GERD Seizures
Clotting Disorder Glaucoma Stroke
Congestive Heart Failure Hepatitis Ulcerative Colitis

Personal Surgical History: Have you ever had any of the following surgeries? (Check if yes)

Adrenal Gland Surgery Colon Surgery Kidney Surgery

Appendectomy Coronary Artery Bypass Graft Neck Surgery
Bariatric Surgery Esophagus Surgery Prostate Surgery
Bladder Surgery Gastric Bypass Surgery Small Intestine Surgery
Breast Surgery Hemorrhoid Surgery Spine Surgery
Cesarean Section Hernia Repair Stomach Surgery
Cholecystectomy Hysterectomy Thyroid Surgery

List names and dates of surgeries: ________________________________________________________

____________________________________________________________________________________
____________________________________________________________________________________
Medications: ________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Allergies: ___________________________________________________________________________
____________________________________________________________________________________
Family History: Has anyone in your family had any of the following conditions? (Check if yes, and indicate relationship to you)

Cancer/Polyps______________________ Anemia___________________ High Blood Pressure_________________

Colon, Rectum, Anal, Stomach, Breast, Diabetes__________________ Anesthesia Reaction ________________
Prostate, Uterus, Ovaries, Thyroid, Lung, Blood Clots_______________ Bleeding Problems__________________
Blood, Lymphoma Heart Disease _____________ Hepatitis__________________________
Other ______________________________ Stroke____________________ Other_____________________________
Name:__________________________________ Date of Birth:_________ Today’s Date:___________
Social History:
Alcohol use - Never Occasionally Daily Type____________________________________________
Tobacco use - Never Previously, but quit Packs Per Day________ for _______ years
Drugs use - Never Occasionally Daily Type____________________________________________

What is your occupation?____________________________________________________________________________________

Marital Status: Single,Married, Divorced,Widowed,Separated

Name of spouse or significant other ___________________________________________________________

Children: Number of Children______ Number of grandchildren______

Women: Number of pregnancies______ , Number of deliveries______ - Vaginal______, C-sections______,

Miscarriages______, VIPs (abortions) ______

Cancer health habits: (Circle response)

Women Men
Breast: Monthly self-exam Y N Prostate: Yearly rectal exam Y N
Yearly physician exam Y N Yearly PSA blood test Y N
Last mammogram Y N
GYN: Yearly GYN exam Y N
Yearly PAP exam Y N
All
Colon: Yearly rectal exam Y N
Skin: High sun exposure Y N
Yearly stool test for blood Y N
Yearly skin exam Y N
Date of last colonoscopy ______________

Review of Systems: Do you currently have any of the following symptoms or conditions (Check if yes)
General: Nothing in this group Cardiovascular: Nothing in this group
Weight loss–How much ______lbs Chest pain
Loss of Appetite Palpitations
Fever Heart valve problems
Chills Calf pain with walking
Night Sweats Leg swelling
Fainting Spells
Respiratory: Nothing in this group
Eyes: Nothing in this group
Chronic cough
Eye disease or injury
Coughing up blood
Wear glasses or contacts
Short of breath with activity
Blurred or double vision
Short of breath lying flat
Ear, Nose, Mouth, Throat: Nothing in this group Wheezing
Hearing loss Asthma
Ear ache / infection Bronchitis
Ringing in ears Pneumonia
Nose Bleeds
Musculoskeletal: Nothing in this group
Bleeding gums
Joint pain
Mouth sores
rthritis
Sore throat
Back pain
Recent voice change
Muscle weakness
Runny nose / cold
Leg pain with walking
Sinus problems
Leg pain at rest
Neck stiffness / pain
Broken bones _______________________
Enlarged neck glands / masses
Name:__________________________________ Date of Birth:_________ Today’s Date:___________

Digestive: Nothing in this group Neurological: Nothing in this group

Loss of appetite Frequent headaches
Difficulty swallowing Migraines
Early satiety (fill up easy) Weakness
Heartburn Seizures
Nausea Stroke
Vomiting Paralysis
Diarrhea Decreased sensation
Constipation Difficulty with speech
Blood in stool Dizziness
Dark, tarry stools
Abdominal pain Psychiatric: Nothing in this group
Painful bowel movements Anxiety
Poor control of BMs, urgency Depression
Mood swings
Urinary: Nothing in this group Phobias, fears ______________________
Burning with urination Panic attacks
Weak urine stream Suicide thoughts or attempts
Blood in urine
Gas or stool in urine Endocrine: Nothing in this group
Poor control, leakage of urine Heat or cold intolerance
Kidney stones Excessive thirst
Prostate problems Excessive urination
Testicular mass Excessive Sweating
Get up at night to urinate - Number of times per night _____

Gynecologic (female): Nothing in this group Hematologic, Lymphatic: Nothing in this group
Irregular periods - Last period:________________ Prior blood transfusion
Abnormal vaginal discharge Easy bleeding or bruising
Low red blood cell count (anemia)
Breast: Nothing in this group Low white blood cell count
Breast lump Prolonged bleeding with cuts, surgery
Breast pain Swollen glands
Nipple discharge Blood clots
Use of blood thinners
Skin: Nothing in this group Swollen lymph nodes
Rash
Skin infections Allergic, Immunologic: Nothing in this group
Ulcers or sores HIV infection
Yellowing of the skin Hepatitis
Eczema, psoriasis, other ______________ Imune deficiency
Pyoderma gangrenosum, erythema nodosum Antibiotics needed for dental work