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
medication?
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 _________________
Type____________
□ Leukemia __________ □ High Blood pressure ________ □ Osteoarthritis _________________ □ Diabetes ____________________
□ Stroke _____________ □ Bleeding tendency __________ □ Asthma ______________________ □ Goiter ______________________
□ Colitis _____________ □ Alcoholism ________________ □ Psoriasis _____________________ □ Autoimmune Disease __________
SYSTEMS REVIEW
As you review the following list, please check any of those problems, which have significantly affected you.
CONSTITUTIONAL
GASTROINTESTINAL
INTEGUMENTARY (SKIN AND/OR BREAST)
 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
GENITOURINARY
EARS–NOSE–MOUTH–THROAT
 Sensitivity or pain of hands and/or feet HEMATOLOGIC/LYMPHATIC
CARDIOVASCULAR
RESPIRATORY
PSYCHIATRIC
MUSCULOSKELETAL
ENDOCRINE
ALLERGIC/IMMUNOLOGIC
List joints affected in the last 6 mos.  Increased susceptibility to infection Patient’s Name Date Reviewed: Physician Initials ___________

Source: http://newportortho.com/wp-content/uploads/2013/02/Health-History-Questionaire.pdf