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New Patient Information

Name:__________________________________________________Date of Visit:______________________________________Age:________

Current Medications:___________________________________________________________________________________________________

Allergies (food and medications):__________________________________________________________________________________________

Reason for visit:_______________________________________________________________________________________________________

Past Medical History: List any major illnesses, hospitalizations or diagnosis: (i.e., high blood pressure, diabetes, depression, reflux, arthritis…) please include dates _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Past Surgical History: Please list any surgeries and dates: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Social History Occupation:______________________________________________________Number of Children_________________

Do you smoke?_____How much?___________ Have you ever smoked?______ For how long?______ When did you qui?t______________

Do you drink alcohol? ________How much?_______________Have you ever used illegal drugs? _________________________________________

Have you traveled out of the state or country ?________Where?___________________________________________________________________

Have you used antibiotics in the last 3 months?__________________________Do you have any pets?______What type?______________________

Family History: What diseases do you have in your family? (high blood pressure, diabetes, heart attack, colon cancer or other diseases)______________________________________________________________________________________________________________

Do you have: (you may circle any of these symptoms or add other you have had)

General: fevers, sweats, chills, weight loss or gain, appetite or sleep changes?

Heart: chest pain, difficulty breathing, swelling, dizzy, rapid heart rate?

Lungs: cough, painful breathing, wheezing, pneumonia, asthma or COPD?

Urinary: painful urination, frequency, night urination, blood or other discharge in your urine?

Muscles/bones: fractures, injuries, pain or stiffness?

Skin: itching, rash, swelling, changes in breast tissue?

Nerves: head injury, headaches, dizzy, fainting, seizures, stroke, trembling?

Psyc: depression, anxiety, difficulty coping or sleeping, forgetfulness?

Metabolism: dry, sweaty or changes in skin color, voice changes, excess hair growth, heat or cold intolerance, tremor?

Blood: anemia, bruising easily, excess bleeding, pale, blood transfusions, swollen lymph nodes?

Allery: hayfever, frequent sinus infections, eczema or itchy skin?

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