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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 |

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|Past Medical History |

|Have you been treated for any of the following conditions? Please circle all that apply. |

|Cardiovascular |

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|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 |

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|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 |

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|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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