NEW PATIENT MEDICAL INFORMATION		Today's date ________________

Name ________________________________________________________    DOB __________________________
Contact in case of emergency (name and contact numbers) ____________________________________________________

Health Care Proxy ______________________________
Do you have a living will? Yes / No   Who has this information if needed?  _________________________________________
What are your wishes regarding CPR/Resuscitation? _________________________________________________________

Your e-mail address ________________________________________
Home Phone ___________________________ Cell Phone _______________________ May we text you? Yes / No 

CURRENT CONCERNS - IN ORDER OF YOUR PRIORITY

ALLERGIES  - with reaction

CURRENT MEDICATIONS - Including Rx, supplements, vitamins, inhalers, as needed meds, aspirin, etc...

PAST MEDICAL HISTORY - include problem, when it started or was diagnosed, doctor's name who has been treating it

PAST SURGICAL HISTORY -  include what was done, surgeon, year and any complications

FAMILY HISTORY - Include children, siblings, parents, grandparents and indicate if alive or deceased and cause of death
Also any health issues they may have or have had i.e prostate cancer, breast cancer, heart disease, etc...

SOCIAL HISTORY - 

Work _____________________ Sports/Hobbbies _______________________Religious preference ____________
Exercise - what you do and how often ________________________________________________________________
Alcohol intake - Type and how many each day/week ________________________
Smoking history - Current smoker? _______ Ever smoked? ______If so-when did you quit? ________
How many years total?__________How many cigarettes/day on average during that time?_________
Any illicit drug use?  ___________If yes - what substance? _______________ Marital status ___________________

HEALTH CARE MAINTENANCE

Immunizations (please enter year given) - Tetanus ________ (with/without pertussis?) Shingles vaccine ________
Pneumonia vaccine _________ Flu vaccine ________ Hepatitis B vaccine________Other ___________________

Colonoscopy year _______ who performed it? __________________ When due again? ______________
Mammogram  ___________ Pap smear_______________ Do you still GYN? Yes/No Name________________
Eye exam  ________________Dental care______________ Fasting Labwork _____________
PSA/Prostate exam ___________ Bone Density test __________________
Other tests (stress test, carotid ultrasound, etc...) _________________________________________________

REVIEW OF SYSTEMS

Please circle any that you often have or wish to discuss:

Weight gain/loss   Fatigue     Fever/chills    Soaking night sweats	Feeling depressed/hopeless/sad/suicidal
Insomnia    Not feeling refreshed upon awakening        Anxiety      Stress

Eye pain    Vision loss   Glaucoma    Dry eyes   Blurred vision   Double vision   Discharge

Ear pain   Decreased hearing    Ear infections    Tinnitus    Nosebleeds    Sore throat   Nasal congestion
Nasal allergies    Sinus pain/pressure   Sinus infections   Tooth decay

Cough   Wheezing   Sputum production   Shortness of breath   Sleep apnea    TB exposure

Excessive hair loss   Thyroid problems   Swollen glands    Choking on liquids/solids 

Low back pain    Neck pain/stiffness   Arthritis   Loss of height   Osteoporosis  Muscle pain
Muscle or joint stiffness lasting longer than 30 minutes   Gout  Fibromyalgia

Palpitations  Heart murmur   Chest pain   Swelling in feet/legs    Fainting  Lightheadness

Abdominal pain    Nausea/vomiting    Gas/bloating   Diarrhea   Constipation  Blood in/on stool
Hemorrhoids   Change in bowel habits

Absence of menses   On hormones- past / present      Irregular periods   Hot flashes   
Vaginal dryness   Lack of sex drive    Abnormal paps
Painful intercourse 

Leakage of urine with cough/sneeze   Urge incontinence   Nightime urination  Blood in urine
Kidney stones    Kidney dysfunction
Dribbling/Hesitancy/Slow stream   Scrotal or testicular pain   Impotence

Pain in legs with walking   Vein problems in legs    Restless legs    Arterial circulation problems
Limb cramps

Memory loss  Unsteady gait/balance problems  Neuropathy   Tremor    Frequent falls  Seizures
Vertigo  Dizziness  

Rashes    Psoriasis    Eczema    Nail fungus   Suspicious moles   Skin cancers

Alcohol abuse/dependence/treatment (past or current)     Drug abuse (past or current)  

Bleeding issues   Bruising    Immune problems    Anemia   Frequent infections

OTHER SYMPTOMS YOU THINK THE DOCTOR NEEDS TO KNOW ABOUT IN THE PAST
OR CURRENT