New Patient Form

New Patient History

Name *

First

Last

Telephone number : *

Birth Date *

Address : *

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 ?

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 ? *

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 ?

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

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27 W. Micheltorena
Santa Barbra Ca. 93101

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