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Call: +(805) 687-1505
Call: +(805) 687-1505
New Patient History
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Name
*
First
Last
Birth Date
*
Age
Selected Value:
18
Email
*
Allergies and Reactions
Medications ( Please List All )
Medications / Dose / Times Per Day
Occupation ( or prior occupation ) :
Employer
Checkboxes
Retired
Unemployed
LOA
Disabled
If employed do you work the night shift :
Yes
No
N / A
Do you have children ?
Yes
No
If yes, how many ?
Marital Status ( check one ) :
Single
Partner
Married
Divorced
Widowed
Other :
Previous Results
Colonoscopy
Cholesterol Panel
Mammogram
Pap Smear
Bone Denisty
Please check any that apply. Include the date and any abnormal results in the Other section, or bring it to your office visit.
Vaccination History
Tetanus or TdaP :
Flu Vaccine :
Zoster / Shingrex Vaccine
Peunovax / Pneumonia :
Prevnar
HPV / Gardicil
Check every vaccine if you have received. Providing the date would be helpful. Include this information in the other section if you can.
Family Medical History
Check if No Significant Family History, or Unknown
Alcohol/Drug Abuse
Asthma
Cancer
Depression/Anxiety/Bipolar/Suicidal
Diabetes
Emphysema or COPD
Heart Disease
High Blood Pressure
High Cholesterol
Hypothyroid
Kidney Disease
Headache / Migraine
Stroke
Other :
Date of Last Menstrual Cycle / Menopause
Number of Pregnancies / Number of Live Births if different :
Please include any Pregnancy Complications :
Other Health Issues
Tobacco Use
Alcohol
Marijuanna
Drugs ( not prescribed )
Sexually Active
Birth Control
Please include in "other" the number and type of tobacco, packs per day, years of use. Include number of drinks and type. Birth Control type ( if used ) condoms, pill, vesectomy
Recent ( 30 days ) Travel outside the US ?
*
Yes
No
Type and Frequency of Exercise :
Sleep :
How many hours a night ? Do you work the night shift ?
Diet Description :
Good
Fair
Poor
Would you like advice on your diet ?
Yes
No
Are you in the military ?
Yes
No
Retired / Discharged
Surgical History
Please include the type / side / Date / and location of any previous or anticipated surgeries.
Personal Medical History
Alcohol or Drug Abuse
Asthma
Cancer
Diabetes
Heart Disease
Depression / Suicidal / Anxiety / Bipolar
Hypertension ( High blood pressure )
Emphysema ( COPD )
Hypercholesterol ( High Cholesterol )
Hypothyroid / Thyroid Disease
Renal ( Kidney ) Disease
Migraine or Headaches
Stroke
Other
Other Specialists
Example : J. Kaye / Internist / 01-01-1990
Comment
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+(805) 687-1505
Reach Us
27 W. Micheltorena
Santa Barbra Ca. 93101
Open Hours
Mon-Fri 8:30am - 5:30pm Sat-Sun On Call
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