New Patient History Form

Todays Date
Nickname
Patient Last Name
Patient First Name
Patient Middle Initial
Responsible Party
Street Address
City
State
Zip
Sex Male Female
Age
Date of Birth
Home Phone
Cell Phone
Email
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
ARMS
BACK
FEET
HANDS
HIPS
LEGS
NECK
SHOULDERS
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