New Patient Questionnaire

Patient First Name

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Patient Last Name

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DOB

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Date:

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Healthcare Specialists:

Specialist-Condition

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Name

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Phone

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Last Seen

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Specialist-Condition

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Name

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Phone

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Last Seen

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Specialist-Condition

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Name

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Phone

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Last Seen

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Specialist-Condition

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Name

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Phone

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Last Seen

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Specialist-Condition

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Name

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Phone

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Last Seen

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Specialist-Condition

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Name

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Phone

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Last Seen

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Allergies

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Allergen

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Reaction

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Allergen

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Reaction

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Allergen

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Reaction

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Allergen

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Reaction

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Health Screening:

Test

Bone Density

When

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Where

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Results

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Cholesterol

When

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Where

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Results

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Colonoscopy

When

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Where

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Results

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Cologuard

When

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Where

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Results

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Dental Exam

When

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Where

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Results

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Glucose

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Where

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Results

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PSA/prostate

When

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Where

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Results

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Eye Exam

When

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Where

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Results

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Mammogram

When

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Where

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Results

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Pap Smear

When

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Where

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Results

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Immunizations

TDAP

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MMR

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Pneumonia

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Hepatitis A

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Hepatitis B

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Shingles

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Prevnar

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Flu

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Medical History: (please check any conditions you have been diagnosed with)

ADHD

Anemia

Anxiety

Arthritis

Bipolar

Cancer

Clotting Issue

Constipation

Depression

Diabetes Type I

Diabetes Type II

Epilepsy/Seizures

Gallstones

Glaucoma

Fibrocystic Breast

Fibromyalgia

Heart –Artery Disease

Hearing Issues

Heart – Murmur

Heart –Valve

Herpes – Genital

High Blood Pressure

High Cholesterol

HIV

Hyperthyroid

Hypothyroid

Irritable Bowel

Kidney Infection

Kidney Stones

Mental Illness

Migraine Headaches

Ovarian Cyst

Pneumonia

Pulmonary Embolism

Stroke

Transfusions

Tuberculosis

Ulcer

Urinary Incontinence

STD

Vision Problems

Additional Details regarding above AND/OR Problems not listed above:

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Past Surgical History:

Surgery

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Surgeon

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Date

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Surgery

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Surgeon

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Date

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Surgery

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Surgeon

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Date

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Surgery

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Surgeon

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Date

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Surgery

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Surgeon

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Date

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Surgery

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Surgeon

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Date

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Surgery

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Surgeon

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Date

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Family Medical History:

Mother:

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Father:

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Siblings:

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Maternal Grandmother

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Maternal Grandfather:

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Paternal Grandmother:

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PaternalGrandfather:

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Children:

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Other pertinent Medical History:

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Social History:

Marital Status:

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Children:

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Ages

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Who do you live with?

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Education: Last Grade completed

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Occupation:

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Occupation Status

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Exercise: Type

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How often

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Wear Seatbelt:

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Tobacco Use:

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Type/Frequency

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How do you Identify?

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Other

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Sexual Activity: Sexually involved currently

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Sexual Partner is/are/have been

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Drug use: Any illicit drug use

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Type/Frequency

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Medication List (you can bring your own list)

Name

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Dose

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Frequency

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Start Date

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Reason

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Name

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Dose

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Frequency

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Start Date

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Reason

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Name

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Dose

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Frequency

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Start Date

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Reason

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Name

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Dose

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Frequency

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Start Date

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Reason

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Name

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Dose

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Frequency

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Start Date

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Reason

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Name

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Dose

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Frequency

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Start Date

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Reason

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Name

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Dose

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Frequency

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Start Date

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Reason

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Name

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Dose

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Frequency

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Start Date

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Reason

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Name

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Dose

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Frequency

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Start Date

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Reason

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Name

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Dose

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Frequency

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Start Date

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Reason

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Name

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Dose

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Frequency

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Start Date

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Reason

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Pharmacy

Name/Number

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Local:

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Mail Order:

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