Microsoft word - new patient history form_new logo.doc

Patient Health History
Name: ___________________________________________________________________ Date of Birth: _____/___/_____Age: _____ Sex: F M Height:_______ Weight :_______ Primary Language: ________________Do you need an interpreter? _____ Referred here by (check one)  Self Family Friend Doctor Other Health Professional
Name of person making referral: _______________________________________________________________________________ Primary Care Physician: ___________________________ Internist: _____________________ Cardiologist: ___________________ Have you had a recent medical evaluation by one of these doctors? _________ Name of Doctor: ____________________________ Past Medical History
In the past 4 weeks, have you had a cough, cold, sore throat or bronchitis that required treatment? ____________ Do you now or have you ever had any of the following? (if yes, check box)  □ Cancer Type:_____________ □ Anemia
List any other conditions you have had that are not already noted

Current Medications
(List any medications you are taking. Include such items as aspirin, vitamins, laxatives, calcium and other supplements)
Drug Allergies: Yes ________ No __________ To What? _______________________________________________________
Type of Reaction:________________________________________________________________________________________
Name of Drug
Dose (include
How long have
Please check: Helped?
strength &
you taken this
number of pills
A Lot Some Not At All
Have you used blood thinners, such as Coumadin, Heparin, Aspirin, Ibuprofen, Alleve, or Plavix, with in the past 2 weeks? ___________ Have you ever taken steroids, such as Prednisone or Medrol, by mouth? ____________ If yes, when and for how long? ____________ Do you take medication for Osteoporosis such as Fosamax, Actonel, or Boniva? _____________________________________________ Date of last EKG_____/_____/______ Date of last Blood draw _____/____/______ Patient’s Name Date Reviewed: Physician Initials ___________ List All Surgeries

Social and Family History
Have you ever smoked? □ Yes □ No Quantity/Amount:_____________ If quit, how long ago? ________________________________
Do you drink alcohol? □ Yes □ No number per week ___________ Has anyone ever told you to cut down on your drinking? □ Yes □ No
Do you use recreational drugs, such as marijuana, cocaine, meth? □Yes □No If yes, please list_________________________________
Do you know of any blood relative who has or had any of the following? (check and indicate relationship)
□ Cancer ____________ □ Heart Disease _____________ □ Rheumatoid Arthritis ____________□ Tuberculosis _________________
□ Leukemia __________ □ High Blood pressure ________ □ Osteoarthritis _________________ □ Diabetes ____________________
□ Stroke _____________ □ Bleeding tendency __________ □ Asthma ______________________ □ Goiter ______________________
□ Colitis _____________ □ Alcoholism ________________ □ Psoriasis _____________________ □ Autoimmune Disease __________
As you review the following list, please check any of those problems, which have significantly affected you.
 Vomiting of blood or coffee ground material  Stomach pain relieved by food or milk  Color changes of hands or feet in the cold NEUROLOGICAL SYSTEM
 Sensitivity or pain of hands and/or feet HEMATOLOGIC/LYMPHATIC
List joints affected in the last 6 mos.  Increased susceptibility to infection Patient’s Name Date Reviewed: Physician Initials ___________


Microsoft word - member matters-englishfinal.doc

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