New Patient Packet

Step 1 of 8

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Name(Required)

D.O.B(Required)

MM slash DD slash YYYY

Age(Required)

Email(Required)

Gender(Required)

Male

Female

Primary Language(Required)

Translator Needed

Yes

Purpose of initial visit(Required)

Weight(Required)

Height(Required)

Name of preferred pharmacy?

Location / Phone

PAST MEDICAL HISTORY

Do you now and ever had:

Diabetes

High blood pressure

High cholesterol

Hypothyroidism

Goiter

Cancer

Leukemia

Psoriasis

Angina

Heart Problems

Sleep apnea

Heart murmur

Pneumonia

Pulmonary embolism

Asthma

Emphysema

Stroke

Epilepsy (seizures)

Cataracts

Kidney disease

Kidney stones

Crohn's disease

Colitis

Anemia

Jaundice

Hepatitis

Stomach or peptic ulcer

Rheumatic fever

Tuberculosis

HIV/AIDS

PID

Other medical conditions (please list):

Surgery / Procedures History:(check all that apply)

Appendix

Bladder Suspension

Blood vessel surgery

Arteries

Veins

Cesarean Section

Colon / Rectal surgery

Dental surgery

Ear surgery

Eye surgery

Gallbladder

Heart Procedure / Surgery

Bypass

Heart valve surgery

Cardiac Ablation

Angioplasty (balloon)

Cardiac Stent

Defibrillator

Pacemaker

Hernia Repair

Hysterectomy Complete

Hysterectomy Partial

Joint replacement / Orthopedic surgery

Ankle

Back

Knee

Neck

Shoulder

Wrist

Kidney surgery

Organ transplant

Prostate surgery

Thyroidectomy

Sinus surgery

Tonsils and / or adenoids

Tubal Ligation

Vasectomy

Aesthetics / Plastic surgery

Have you ever had a blood or blood products transfusion ?

Yes

if so, when was last transfusion:(Required)

Please list any hospitalizations in the past:(Required)

FAMILY MEDICAL HISTORY

Adopted

Unknow history

Mother living

Father living

please check if your family member had any of the conditions below:

SOCIAL HISTORY

Where were your born & raised ?(Required)

What is your highest education ?(Required)

High school

Some college

College graduate

Advanced degree

Marital status(Required)

Never married

Married

Divorced

Separated

Widowed

Partnered/significant other

What is your current and past occupation?(Required)

Are you currently working ?(Required)

Yes

Hours/week(Required)

If not, are you(Required)

retired

disabled

sick leave

SOCIAL HISTORY SAFETY

Do you wear a seat belt ?

Yes

Do you wear a bike helmet ?

Yes

Do you have a working smoke detector in your home ?(Required)

Yes

Is there a gun in your home ?(Required)

Yes

Is it unloaded and out of reach of children ?(Required)

Yes

Have on Organ Donor Card ?

Yes

Do you have a living Will or advance Directive for Healthcare ? (if yes please provide copy to office)

Yes

Do you smoke?(Required)

Currently

Past

Never

packs/day

for many years

Quit Date

MM slash DD slash YYYY

Other nicotine use such as smokeless tobacco or vaping

Yes

Exposure to second hand smoke?

Yes

Marijuana

Yes

Do you drink alcohol?

Beer

Wine

Liquor

How many drinks per week?

How many caffeinated beverages per day?

Beverages

Coffee

Tea

Sodas

Energy Supplements

Recreational drug use?

Yes

Do you exercise regularly?

Yes

how many times per week?(Required)

Type of exercise:(Required)

How many hours of sleep do you get per night?

Do you wake feeling well rested?

Yes

SOCIAL HISTORY Sexual History

Sexually active currently ?(Required)

Yes

How many partner in last 5 years ?(Required)

Partner(s) is/are/have been:

Male

Female

Both

Birth control method:

None

Condom

Pill/Ring/Patch/Injection

UID

Tubal Ligation Vasectomy

Have you ever experienced ? Sex with an IV drug user ?

Yes

Sex with a person with HIV/AIDS ?

Yes

Sex while using drugs ?

Yes

Sex for drugs / money ?

Yes

Ever been a victim of sexual assault ?

Yes

Do you feel safe in your home ?

Yes

Are you in a relationship which you have been physically hurt ?

Yes

Do you ever feel afraid of your partner ?

Yes

Are you from or have you traveled to a part of the world with a high TB prevalence ?

Yes

if yes, please explain(Required)

Have you been in contact with persons with confirmed TB ?

Yes

if yes, please explain(Required)

Are you in contact with any of the following persons ?

Homeless persons ?

Yes

IV / Street drug users ?

Yes

Institutional / incarcerated person ?

Yes

Migrant farm workers ?

Yes

HIV+ person ?

Yes

Resident of nursing homes ?

Yes

Any yes, please explain

Preventative Care History (Date of last) :

Complete Physical

MM slash DD slash YYYY

Dental Exam

MM slash DD slash YYYY

Breast Exam

MM slash DD slash YYYY

Eye Exam

MM slash DD slash YYYY

TB Test

MM slash DD slash YYYY

Hearing Test

MM slash DD slash YYYY

Bone density (DEXA) Exam

MM slash DD slash YYYY

Cholestrol Check

MM slash DD slash YYYY

Check for blood in stool

MM slash DD slash YYYY

Mammogram

MM slash DD slash YYYY

Prostate Exam

MM slash DD slash YYYY

PAP Smear

MM slash DD slash YYYY

Vaccination History (Immunization Year) :

COVID

Flu

Hepatitis B

Pneumonia

Tetanus

Shingles

RREVIEW OF BODY SYSTEMS

In the past month, have you had any of the following problems ?

GENERAL

Recent weight gain

Recent weight loss

Fatigue

Weakness

Fever

Night sweats

NERVOUS SYSTEM

Headaches

Dizziness

Fainting or loss of consciousness

Numbness or tingling

Memory loss

STOMACH AND INTESTINES

Nausea

Heartburn

Stomach pain

Vomiting

Yellow jaundice

Increasing constipation

Persistent diarrhea

Blood in stool

Black stools

PSYCHIATRIC

Depression

Excessive worries

Difficulty falling asleep

Difficulty staying asleep

Difficulties with sexual arousal

Poor appetite

Food cravings

Frequent crying

Sensitivity

Thoughts of suicide / attempts

Stress

Irritability

Poor concentration

Racing thoughts

Hallucinations

Rapid speech

Guilty thoughts

Paranoids

Mood swings

Anxiety

Risky behavior

MUSCLE JOINTS BONES

Numbness

Joint pain

Muscle weakness

Joint swelling

EARS

Ringing in ears

Loss of hearing

EYES

Pain

Redness

Loss of vision

Double or blurred vision

Dryness

SKIN

Redness

Rash

Nodules bumps

Hair loss

Color changes of hands or feet

THROAT

Frequent sore throats

Hoarseness

Difficulty in swallowing

Pain in jaw

HEART AND LUNGS

Chest pain

Palpitations

Shortness of breath

Fainting

Swollen legs or feet

Cough

Blood

Anemia

Clots

KIDNEY / URINE / BLADDER

Frequent or painful urination

Blood in urine

Leakage of urine

Women only:

Date of LMP

MM slash DD slash YYYY

Number of days between cycles

Length of period

Age onset first period

Age of menopause

PMS

Pelvic Pain

Abnormal Pap

Treatment

Irregular Periods

Bleeding between periods

Vaginal Dryness

Vaginal Discharge

Age of first pregnancies

Total number of pregnancies

Abortions / Miscarriages

Total number live births

Live children now

Do you have any ALLERGIES?

Drug Allergies

Aspirin NSAIDS Penicillin Sulfa Contrast Dye Iodine

None

Food Allergies

Peanuts Soy Wheat Tree Nuts Shellfish Fish Strawberries

None

Environmental Allergies

Latex Bees Wasps Cats Dogs Grass Pollen

None

Do you take any medications or supplements on a daily basis? If yes please list below:

Name

Strength

How Often ?