New Patient History

First Name

Last Name

Date of Birth

Sex

Male

Female

Age

Primary Care Provider

Referring Provider

Chief Complaint

How long?

Past Medical History

Past Medical History

Asthma

Hay Fever/ Seasonal Allergies

History of TB or Exposure to TB

History of Heart Attack

High Blood Pressure

Night Sweats

Depression

Seizures

Hallucinations

Have you ever had psychiatric help?

History of Hepatitis

Extended muscle pain or weakness

Arthritis

Painful Urination

Diabetes

Thyroid Disease

Sensitivity to Cold

History of Eczema

History of Psoriasis

History of Blood Transfusions

History of Intravenous drug abuse

Cancer

Yes

No

If yes, what type?

Have you been tested for HIV?

Yes

No

If yes, what was the result?

Reactions or allergies to local anesthetics such as those used by a dentist? If yes, Please list

Bleeding disorders, frequent nosebleeds, easy bruising or bleeding longer than most. If so, please list.

Have you ever fainted

Yes

No

Do cuts on your skin heal with normal scars?

Yes

No

Are you allergic or have had a bad reaction to any substance applied to your skin?

Yes

No

Have you had previous cosmetic surgery

Yes

No

Have you had a colonoscopy (45-75 years of age)?

Yes

No

If so, when?

Do you have normal periods?

Yes

No

Do you have excessive body hair?

Yes

No

Could you be pregnant?

Yes

No

Are you planning to become pregnant?

Yes

No

Have you had a mammogram? (50-75 years of age)

Yes

No

If so, when?

Current Medication List (Include Medication Name, Dosage, & Frequency)

Drug Allergies - Medication & Reaction

Social History

Alcohol Usage

Currently Every Day

Currently Some Days

Former

Never

If currently every day amount and type:

If former, quit date?

If currently every day amount and type:

If former, quit date?

Past Surgical History

If other, what type of surgery?

Past Hospitalizations (List below with dates and include child birth)