New Patient Health History

Patient Name*
First Name Last Name
Age in years*
Date
Reason for visit*
(1 ) VITALS weight in pounds*
(1) VITALS height in feet and inches*
(2) ACTIVE MEDICATIONS: Include dose and start date of each current med.*
(3) ALLERGIES to meds*
(4) MEDICAL HISTORY list all medical diagnoses, issues*
Surgeries
Family History: List major medical problems, whether deceased, and cause:
Mother
Father
Sisters
Brothers
Children
(5) SMOKING STATUS
- Current smoker
- Former smoker
- Never smoker
HEALTH MAINTENANCE
List last test date approx. MONTH /YEAR and RESULT
Bone density month/year result
Breast mammogram month/year result age 40yrs and up
Colonoscopy month/year result age 50yrs and up
Eye exam
Heart test month/year result
Immunization History list date of last vaccination
Flu
Gardisil
Hep B
Tetanus
Pneumonia
Zoster shingles
PAP SMEAR month/year result females
PSA Prostate lab test month/year result and last prostate exam males
Check the box if you have recently had symptoms
- Abdominal pain
- Allergy symptoms
- Anxiety, stress, worry
- Back pain
- Balance, falls
- Bleeding
- Chest Pain
- Constipation
- Cough
- Depression
- Diarrhea
- Diet, nutrition
- Dizzy
- Fatigue, tired
- Fever
- Headache
- Hearing
- Joint pain
- Memory
- Muscle aches
- Nausea, vomiting
- Numbness
- Palpitations
- Sexual
- Sinus symptoms
- Skin rash
- Sleep
- Urinary symptoms
- Vision
- Weakness
- Weight gain
- Weight loss
- Other
Alcohol # drinks weekly
Exercise #hours weekly
Recreation and exercise activities
Type of employment
Check topics interested in
- Age Management
- Exercise, peak performance
- Hormone balancing
- Medical massage, lymphatic drainage
- Nutrition, diet plan
- Qi gong
- Stress reduction
- weight management
- ealth risk reduction
Other topics interested in
Untitled
- Yes
- No
Would like health improvement newsletter
- Yes
- No
Name of preferred PHARMACY
Pharmacy address with cross streets
Pharmacy address with cross streets
Pharmacy tel.
List other physicians and specialties:
Social History (request by ins.)
- Single
- Married
- Divourced
- Widowed
Race (request by ins.)
- AA
- Asian
- Hispanic
- Native American
- White
- Other
Emergency contact name
Emergency contact relationship
Emergency contact telephone
Emergency contact address
Living will?
- Yes
- No
Name and contact info. for Healthcare Surrogate or Power of attorney
Please take a moment to provide all requested health information, for your medical benefit. Agreement: I, the patient, have provided all of my medical information above and agree to: 1 Review all test results and condition changes at medical office visits, as these are reviewed during appointments only. 2 Obtain all medicine refills at scheduled office visits, and make sure that I have enough medicine until the next recommended visit. 3 Schedule recommended visits, for my medical safety and benefit. 4 Be responsible for providing test results, outside of the office network of DCA, Quest, Labcorp, Boca Hospital, to the medical office. 5 Call 911 or go to the Emergency Room for emergency problems, which cannot wait for an office visit. 6 Assume responsibility for my health outcomes, if I elect not to follow medical recommendations. By completing the boxes below, with my name and date, I am indicating agreement with the above.
Full Name
First Name Last Name
Date