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PATIENT DEMOGRAPHIC INFORMATION
|PATIENT INFORMATION |
|Today’s Date: |MRN: |Account Number: |
|Patient Name: |Nickname: |
|Mailing Address: |
|Email Address: |
|Home Phone: Cell Phone: Work Phone: |
|Can we leave |
|a message? □ Y □ N □ Y □ N □ Y □ N |
|DOB: |Sex: |Marital Status: |
|EMERGENCY CONTACT INFORMATION |
|Emergency Contact Name: |Phone Number: |
|RESPONSIBLE PARTY |
|Guarantor Name: |DOB: |
|Address: |
|INSURANCE INFORMATION |
|Primary Insurance: |Secondary Insurance: |
|Address: |Address: |
|Phone Number: |Phone Number: |
|Subscriber Name: |Subscriber Name: |
|DOB: |DOB: |
|Subscriber ID: |Subscriber ID: |
|Group Number: |Group Number: |
|EMPLOYER INFORMATION |
|Patient Employer: |Patient Occupation: |
|ADVANCED DIRECTIVE |
|Please provide our office with a copy and check the box if you have any of the following in place: |
|□ POA □ Living Will □DNR □None |
|ETHNICITY/RACE/LANGUAGE |
|Which category best describes your race? Please select all that apply |
|□ African American □ Asian □ Caucasian □ Other__________ □ Decline to answer |
|Are you of Hispanic or Latino descent? □ No □ Yes □ Decline to answer |
|What is your preferred language? |
|□ English □ Spanish □ French □ Other______________ |
Medical Hills New Patient Information Name: DOB:
|Current Medications |
|Prescribed Medications |Size |Dose |Frequency |Prescriber |
|Lipitor(example) |40mg tablet |1 tablet |Once a day |Dr. Med Hills |
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|Medication Allergies / Intolerances |
|Please list medications you are allergic to |Reaction: |
|(or cannot tolerate). | |
|Example: Penicillin |Example: rash, difficulty breathing |
| | |
|Past Medical History |
|Have you been treated for any of the following conditions? Please circle all that apply. |
|Cardiovascular |
| |
|Mental Health History |
|Circle any of the following conditions that you have been treated for in the past: |
|Depression |Drug abuse |ADHD |
|Suicide attempt |Alcoholism |Bipolar disease |
|Anxiety |Eating disorder |Obsessive-compulsive disorder (OCD) |
|Panic attacks |Posttraumatic stress disorder |Psychosis |
|Other: |
|Specialists/Other Medical Care |
|Are You Currently Under The Care/Supervision Of Any Other Physician For Any Aspect Of Your Medical Care? |
|☐ Yes ☐ No |
|If yes, please list the physician and condition they are treating you for: |
|Physician |Condition being treated |
| | |
| | |
| | |
|Sexual History |
|Are you currently sexually active? NO YES Type of contraception: |
|Have you been sexually active in the past? NO YES |
|How many total sexual partners have you had in your lifetime? |
|Have you ever been treated for a sexually transmitted disease? NO YES Type: |
|Examples of STD’s: gonorrhea, chlamydia, genital warts, herpes. |
|Are you satisfied with your sex life? YES NO Concerns: |
|Women’s Health |
|Bone Health |
|Have you ever had a spine or hip fracture? NO YES |Date of last DEXA Scan: |
| |Date of last Vitamin D level: |
|Has your mom or a sister been NO YES treated for |Do you take supplemental YES NO |
|osteoporosis? |Calcium and Vitamin D? |
|Age of first period: |Are your periods regular? |
|If no longer having periods, how |How often do you have a period? |
|old were you when they stopped? | |
|Total number of pregnancies: |Number of stillbirths: |
|Number of live deliveries: |Number of miscarriages: |
|Gestation diabetes? NO YES |Number of abortions: |
|Pregnancy induced hypertension? NO YES | |
|Surgery/Procedure History |
|Have you had any of the following procedures (please circle)? If you can recall, add date. |
|Tonsillectomy |Carpal tunnel surgery |Vasectomy |Stress test |
|Adenoidectomy |Hip surgery |Prostate surgery |Bypass surgery |
|Cholecystectomy |Knee surgery |C Section |Stent placement |
|Appendectomy |Shoulder surgery |Hysterectomy |Pacemaker |
|Bowel surgery |Foot surgery |Tubal ligation |Neurosurgery |
|Weight loss surgery |Plastic surgery |Cystoscopy |Back surgery |
| |Breast Biopsy |Cardiac catheterization |Cataract surgery |
|Hospitalizations |
|Please list recent hospitalizations: |
|Date |Reason |Hospital |
| | | |
| | | |
|Family History |
|Please indicate any blood relative who has/had the following conditions with an X: |
|Health Problem |
|Circle Y or N for if family is living |
|Occupation |Job description: |Company or place of work: |
|Marital Status |Single Divorced Widowed |What is your spouse’s name? |
| |Married Separated Remarried |(if applicable) |
|Children’s Names | |
|Education |What is your highest level of education? |Where and when did you complete your education? |
|Religion | |Local church or place of worship: |
|Caffeine |Cups of coffee per day: |What do you do for enjoyment? |
|Alcohol |1 drink=12-ounce beer/5 oz wine/1 shot liquor |How many drinks do you have per week? |
| |How many drinks do you have per day? |0 |
| |0 |1-2 |
| |1-2 |3-5 |
| |3-5 |6-9 |
| |6-9 |10 or more |
| |10 or more | |
| | | |
| |Have you ever sought treatment for drug or alcohol use? |No Have you ever had a drink first thing in the morning to steady your nerves |
| |Yes |or get rid of a hangover? |
| |No |Yes |
| | |No |
|Drugs |Which drugs have you taken before (check all that apply)? |
| |___ Methamphetamines (Speed, Crystal) ___ Cocaine |
| |___ Cannabis (Marijuana, Pot) ___ Ecstasy |
| |___ Tranquilizers (Valium) ___ Hallucinogens (LCD, Mushrooms) |
| |___ Inhalants (Paint Thinner, Aerosol, Glue) ___ Narcotics (Heroin) |
| |___ Barbiturates ___ Synthetics |
| |How many times in the last year have you used a street drug? |How often do you use prescription drugs for non-medical reasons |
| |None |Not at all |
| |A few times |Some days |
| |Several times |Several times |
| |Most days |Most days |
|Tobacco |Which of the following tobacco products have you used in the |Do you need support to quit? |
| |last year? |Yes |
| |Smoke cigarettes or cigars |No |
| |Smoke e-cigarettes | |
| |Dip |Have you tried to quit tobacco within the last year? |
| |Chewing tobacco |Yes |
| |Water pipes |No |
| |Hookahs |If yes, how did it go? |
| |Have often do you smoke/use tobacco? | |
| |Not at all | |
| |Some days | |
| |Most days | |
| |Every day | |
|Preventative Care History |
|Colonoscopy |Date of Last: |Results: |
| |☐ Never |☐Abnormal ☐Normal ☐Unknown |
|Mammogram |Date of Last: |Results: |
| |☐ Never |☐Abnormal ☐Normal ☐Unknown |
|Pap Smear |Date of Last: |Results: |
| |☐ Never |☐Abnormal ☐Normal ☐Unknown |
|PSA (Screening for Prostate Cancer) |Date of Last: |Results: |
| |☐ Never |☐Abnormal ☐Normal ☐Unknown |
|Skin Exam by dermatologist |Date of Last: |Results: |
| |☐ Never |☐Abnormal ☐Normal ☐Unknown |
|Flu Shot/Influenza Vaccine |Date of Last: ☐ Never |
|Gardasil (HPV) Vaccine |Date of Last: ☐ Never |
|Pneumonia Vaccine |Date of Last: ☐ Never |
|Tetanus Vaccine |Date of Last: ☐ Never |
|Shingles Vaccine |Date of Last: ☐ Never |
|Hepatitis A Vaccine (2 shot series) |Date of Last: ☐ Never |
|Hepatitis B Vaccine (3 shot series) |Date of Last: ☐ Never |
|Review of Systems |
|Please place an X by any symptoms that you are experiencing today: |
|Constitutional |Respiratory |Gastrointestinal |Musculoskeletal |
|Weight change |Shortness of breath |Nausea |Morning stiffness |
|Fatigue |Difficulty breathing at night |Abdominal pain |Muscle spasms |
|Weakness |Cough |Vomiting |Joint pain |
|Fever |Coughing up blood |Stomach pain relieved by food/milk |Muscle tenderness |
| |Wheezing |Constipation |Joint swelling |
|Ears/Nose/Throat |Swollen legs or feet |Persistent Diarrhea | |
|Pain | |Blood in stools |Allergic/Immunologic |
|Redness |Neurological |Black stools |Frequent sneezing |
|Double or blurred vision |Headaches |Heartburn |Frequent infections |
|Eye dryness |Dizziness |Excessive gas |Skin/Breast |
|Ringing in ears |Sensitivity in hands/feet |Change in appetite |Easy bruising |
|Hearing loss |Memory loss | |Rash/hives |
|Nosebleeds |Night sweats |Genitourinary |New lesions |
|Loss of smell | |Difficulty urinating |Change in mole |
|Sores in mouth |Psychiatric |Pain/burning when urinating |Hair loss |
|Dry mouth |Excessive worries |Frequent urination |Color changes of hands/feet when cold |
|Hoarseness |Anxiety |Blood in urine |Breast lump |
|Difficulty swallowing |Easily loses temper |Discolored urine |Nipple discharge |
| |Depression |Discharge from penis/vagina | |
|Cardiovascular |Agitation |Rash/ulcers |Hematologic/Lymphatic |
|Pain in chest |Difficulty sleeping |Sexual difficulties |Swollen glands |
|Irregular heart beat |Difficulty concentrating |Change in periods |Tender glands |
|Sudden changes in heart beat | | |Anemia |
|High blood pressure |Endocrine | |Bleeds easily |
|Low blood pressure |Excessive thirst | |Blood transfusion |
|Heart murmur |Cold intolerance | |When?___________ |
| |Heat intolerance | | |
|Advanced Directives |
|Which of the following have you completed? |
|( Power of Attorney for Healthcare ( Living Will ( Do-Not-Resuscitate (DNR) Order |
|What questions do you have for your doctor today? What is your MAIN medical concern? |
| |
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Patient Signature:_____________________________________________ Date:_________________________________
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