PRIMARY CARE ASSOCIATES MASS GENERAL WEST NEW PATIENT QUESTIONNAIRE
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1 PRIMARY CARE ASSOCIATES MASS GENERAL WEST NEW PATIENT QUESTIONNAIRE Name: DOB: Date completed: Where have you received health care previously? Do you require a translator? Yes No Do you have any hearing, vision or memory issues we should be aware of? Yes No Explain Specific health concerns to address today: PAST HEALTH HISTORY In the PAST, have you had any problems with any of the following? Cancer, please specify: Skin Disease Headache/Migraine Stroke Multiple Sclerosis Seizure Disorder Traumatic Head Injury Allergies/Recurrent Sinusitis Diabetes Thyroid Disorder Asthma/Emphysema/COPD Other Lung Disorder Heart Attack or Angina Abnormal Heart Rhythm/Heart Valve Problems High Blood Pressure High Cholesterol Heartburn/Reflux/Peptic Ulcer Disease Hepatitis/Liver Problems Other Intestinal Disorders Back Pain/Arthritis/Joint Pain Osteoporosis/Multiple Fractures Rheumatologic Disorders (e.g. RA, Lupus) Kidney Stones Recurrent UTIs/Incontinence Gynecologic Disorder (e.g. Uterus, Ovary) Prostate Disorder Blood Disorders (e.g. Anemia, Blood Clots) Infectious Disease (e.g. HIV, TB) Eating Disorders Depression/Anxiety or Panic Attacks Yes No
2 SURGICAL HISTORY Year: Procedure: Year: Procedure: Year: Procedure: Year: Procedure: HOSPITALIZATIONS Year: Reason: Year: Reason: Year: Reason: Year: Reason: FAMILY HISTORY Please list medical problems for blood relatives, especially history of: HIGH BLOOD PRESSURE, HEART PROBLEMS, CANCER, BLOOD CLOTS, DIABETES, OSTEOPOROSIS, AND AUTOIMMUNE DISORDERS. Mother Maternal Grandmother Father Maternal Grandfather Brother Paternal Grandmother Sister Paternal Grandfather Others ALLERGIES Have you ever had a life-threatening allergy reaction (i.e. anaphylaxis)? YES If yes, please explain: Drug Allergy: Reaction: Food/Other Allergies: Reaction: NO MEDICATIONS Please list all prescription, nonprescription, natural products or vitamins you currently take: Drug Name: Dosage: Frequency: How long taken:
3 HABITS Do you smoke? If yes, how many cigarettes/day? Would you like to quit? Did you smoke in the past? If yes, how many cigarettes/day? Total years smoked: How often do you have a drink containing alcohol? Never (0) Monthly or less (1) 2-4 times/month (2) 2-3 times/week (3) 4 or more times/week (4) When you drink, how many drinks do you typically have? 1 or 2 (0) 3 or 4 (1) 5 or 6 (2) 7-9 (3) 10+ (4) How often did you have six or more drinks on one occasion in the past year? Never (0) Less than monthly (1) Monthly (2) Weekly (3) Daily or almost daily (4) Do you use any non-prescribed drugs (e.g. marijuana, cocaine, heroin, pills)? Have you ever used any of these drugs in the past? HEALTH MAINTENANCE Please indicate if you have received the following tests, with most recent date and result: COLONOSCOPY: MAMMOGRAM: PAP: BONE DENSITY: PSA: EYE EXAM: DENTAL VISIT: Please indicate if you have received the following vaccinations. Measles/Mumps/Rubella Pneumococcal Hepatitis B Meningococcal Tetanus/Diptheria/Pertussis HPV (Gardasil) Chicken pox Flu Have you completed an advanced directive, a living will or durable power of attorney for healthcare? Do you wear a seatbelt on a regular basis? Do you wear sunscreen?
4 WOMEN ONLY Date of last menstruation: How old were you when you had your first period? Do you still menstruate? Yes, regularly Yes, but not regularly No, I no longer have menstrual periods because of: Natural Menopause Hysterectomy Are you currently having problems with pelvic pain, irregular or heavy menses? If yes, please explain: # Pregnancies # Children # Miscarriages # Abortions Have you ever had a breast biopsy? If yes, please explain: Have you ever had an abnormal Pap? YES NO If yes, when: SOCIAL HISTORY Do you live alone? If no, with whom do you live: Occupation: On average, how many servings per day do you have of high calcium foods (e.g. 1 cup of milk, ½ cup of yogurt, 2 oz. of cheese) or a 300 mg Tums or calcium supplement? Do you follow a special diet? If yes, please explain How many cups of coffee do you drink a day? How many times per week do you exercise? Not at all 1-2x 3-4x 5-7x Type of exercise/duration: Have you ever been sexually active? If yes, with men, women, or both? Are you currently in a sexual relationship? Have you ever had a sexual transmitted infection? If applicable, type of birth control you are using: Do you consider religion / spirituality an important part of your life/health? YES NO
5 SAFETY Do you have any concerns regarding domestic or sexual abuse? MENTAL HEALTH Over the last 2 weeks, how often have you been bothered by the following problems? Feeling nervous, anxious or on edge: Not being able to stop or control worrying : Little interest or pleasure in doing things: Feeling down, depressed, or hopeless: Thank you for joining our practice. We welcome your feedback on this questionnaire. If you have any suggestions, please let us know.
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Aspen Medical Group Crista Keller, M.D. Megan Press, M.D. Katherine Johnson, NP-C Susan Esmond, PA-C E. Kendrick Lane, PA-C To our valued Medicare Patients, Medicare will now be covering a free annual
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Background Information & Medical History Form
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