Comprehensive Adult New Patient Health History Questionnaire

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1 Comprehensive Adult New Patient Health History Questionnaire Your answers on this form will help your physician get an accurate history of your medical concerns and conditions. Please fill in as much information as possible. The information provided will help us to properly care for you. If you cannot remember specific details, please provide your best guess. If you are uncomfortable with any question, do not answer it. Thank-you! Who referred you to my practice? Another Patient Family Member Another Doctor Other: _ Main medical concerns: _ Health goals for the next year: _ How would you rate your health? Excellent Good Fair Poor Please list other healthcare providers & their specialty you see regularly: Healthcare Provider Specialty Last Time Seen MEDICATIONS: Please list (or show us your own printed record of) all prescriptions and non-prescription medications. This includes vitamins, herbs, supplements, home remedies, birth control pills, inhalers, over the counter pain pills (Advil, Aleve, Tylenol, etc). Check box if you do not take any prescription or over the counter medications. Check box if you brought a list of your medications (present to front desk staff with this form). Medication Name Dose (i.e., mg/pill) Doses per day (i.e., once daily, three times daily with meals) Do you have any allergies or intolerance to medications? NO YES (If yes, to what & what reaction):

2 IMMUNIZATIONS: Enter year (if known) of any vaccinations you have had. Vaccine Name (Circle if more than one option) Tetanus (Tdap) Varicella (Chicken Pox) vaccine or illness Pneumonia (Pneumovax) Influenza (Flu shot) Hepatitis A, B, A+B (Twinrex) Mumps, Measles, Rubella (MMR) Shingles (Zostavax) HPV (Gardasil) Other (specify): Date/Year Received PERSONAL MEDICAL HISTORY: Do you have now or have you had (in the past) any of the following conditions? Condition Now Past Condition Now Past Alcohol/ Drug abuse Allergies/ Hay Fever Anemia Anxiety Arthritis (Rheumatoid) Arthritis (Osteoarthritis) Asthma Bladder/ Kidney Problems Blood Clot (Legs) Blood Clot (Lung) Blood Transfusion Breast Lumps (Benign) Cancer - Breast Cancer - Colon Cancer - Lung Cancer - Ovarian Cancer - Prostate Cancer Other (specify below) Cataracts Chicken Pox Colon Polyps Gynecological Other (specify below) Heart Attack Hepatitis B Hepatitis C Hepatitis Other (specify below) High Blood Pressure/ Hypertension High Cholesterol Hip Fracture HIV Irritable Bowel Syndrome Kidney Disease/ Failure Kidney Stones Liver Disease Migraine Headaches Osteoporosis Pneumonia Prostate enlargement Seizures/ Epilepsy Skin Condition - Eczema Coronary Artery Disease Skin Condition - Psoriasis Depression Skin Condition - Abnormal Moles Sleep Apnea Diabetes (Adult Onset) Stomach Ulcer Diabetes (Childhood Onset) Stroke Diverticulosis Thyroid Nodule Emphysema/ COPD Thyroid Overactive / Fractured bones (specify below) Hyperthyroidism Gallbladder Disease Thyroid Underactive/ GERD/ Heartburn Hypothyroidism Glaucoma Gout Other (specify below) Specify in this space for any conditions checked: Gynecological Endometriosis Gynecological - Fibroids

3 SURGICAL & PROCEDURE HISTORY: Please check any procedure or surgeries. List any abnormal finding or complications. Surgery/ Procedure Yes Year Comments Abdominal Angiogram (Heart) Angiogram (Vascular) Appendectomy Back/ Spinal Breast Biopsy (specify location) Breast Surgery (specify type and location) Cataracts Colonoscopy Coronary Bypass Coronary Stent C-Section Echocardiogram (Heart Ultrasound) Endoscopy (Esophagus/ Stomach) Gallbladder Removal Heart Surgery Hip Surgery (specify) Hysterectomy (excluding ovaries) Hysterectomy (including ovaries) Knee Surgery (specify) L.E.E.P. (Cervix) Pulmonary Function Test Sigmoidoscopy Sinus Surgery Stress Test/ Stress echo Tonsillectomy Tubal Iigation Vasectomy Other list Check box if you have never had surgery FAMILY HISTORY: Are you adopted? NO YES (If yes, and you do not know your family medical history skip the following section) Indicate which relative has had the following diseases (parents, brothers & sisters are the most important). Write in number of siblings in appropriate boxes. If family members are deceased, use the comments section to explain further. Comments Condition Family Member(s) (age of diagnosis and if this caused family member's death) Alcoholism/ Drug abuse Alzheimer's Asthma Autoimmune Disease Bleeding or Clotting Disorder Cancer Breast Cancer Colon Cancer Lung Cancer Other (specify) Cancer Ovarian Cancer Prostate Colon Polyps

4 Condition Depression Diabetes Type I (Childhood Onset) Diabetes Type ll (Adult Onset) Emphysema/ COPD Glaucoma Heart Disease (specify) Hip Fracture Hyperlipidemia High Cholesterol Hypertension High Blood Pressure Kidney Disease (specify) Kidney Stones Macular Degeneration Osteoporosis Other (specify) Other (specify) Stroke Sudden Cardiac Death Thyroid Disease (specify) Family Member(s) Comments (age of diagnosis and if this caused family member's death) LIFESTYLE HEALTH FACTORS: Tobacco Use: Smoke or smoked cigarettes/ pipe/ cigars (circle)? NO YES Current smoker: Packs/day: Number of years: Former smoker: Quit date: Approximately how many packs/day did you smoke? Alcohol Use: NO YES If yes, how many drinks a week: Recreational Drug Use: NO YES If yes, which one(s) and frequency of use: Sexual Activity: Are you sexually active: NO YES NOT YET Sexual partner(s) is/are/have been/may be in future: MALE FEMALE BOTH Birth control method or STD prevention (check all that apply): None needed Condom Birth Control Pill IUD Patch Nuva Ring Diaphragm Vasectomy Tubal Ligation Other method (specify): Diet: Do you follow a special diet? NO YES If yes, specify: Exercise: Do you exercise regularly? NO YES If yes, specify:

5 EMOTIONAL: In the past 2 weeks: Have you been feeling down, depressed or hopeless? NO YES Have you or any family members ever been threatened or hurt physically and/or emotionally? NO YES If yes, please specify: SOCIAL: Do you live: Alone With a Spouse With Friends With Other Family Members Marital status: Single Partnered Married Separated/Divorced Widowed Number of Children: In the event of an emergency, who would you want your first contact to be (with phone number): ECONOMIC & EDUCATION: Occupation (or prior occupation): Are you currently: Employed Part-time Employed Full-time Unemployed Retired Unable to work because of disability Education: Elementary/High School Trade School Community College University ADVANCED HEALTH DECISIONS: Please check any of the following forms you have completed: Advance Directive for Health Care (ADHC) Enduring Power of Attorney (EPOA) for healthcare decisions Living Will POLST (Physician Orders for Life Sustaining Therapy) I would like more information on completing some or all of these health documents WOMEN'S HEALTH HISTORY: Total number of pregnancies: Number of births: Number of miscarriages: Number of abortions: Age at beginning of periods (menstruation): Age at end of periods (menopause/hysterectomy): Do you have concerns about your periods or menopause you'd like to discuss? NO YES If you are having periods, how often do they occur? Every days. How long do they last? days PATIENT'S SIGNATURE: DATE: Thank you for taking the time to complete this form!

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