Name of Patient: Date of Birth: Last First M.I. How do you wish to be addressed? Age: Sex: M F

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New Patient History & Physical Form (Please complete and bring to your first visit) Name of Patient: Date of Birth: Last First M.I. How do you wish to be addressed? Age: Sex: M F Height: Weight: lbs. What medical problem or condition are you here to have evaluated? Is English your primary language? Yes No If not, do you require an interpreter? Yes No Current Medications: (Please list all prescription, non-prescription medications and nutritional supplements or attach list) CURRENT MEDICATIONS DOSE (strength) SCHEDULE (how many & time per day) HOW LONG HAVE YOU TAKEN Example: Lopressor 50 mg 1 tablet, two times a day 6 months Drug/Food Allergies: Are you allergic to: Yes No Please list all allergies to medications and other substances. Describe reactions they cause. Any medications Iodine, fish or shellfish X-ray dye or IV contrast Can you tolerate aspirin

Previous Operations/Procedures: Year Surgeon Place (hospital or city) Complications / Problems Reasons for other Hospitalizations (Non-Surgical Admissions) Year Physician Place (hospital or city) Please list any other Medical Illnesses, Any other History of Cancer or Chronic Conditions How long have you had this Do you have: Yes No High Blood Pressure. Diabetes Controlled with: Insulin, how long: Pill Diet High cholesterol.. Family history of heart of vascular disease.. A history of Rheumatic Fever or Scarlet Fever.. Have you ever had any of the following Yes No Date or Year Exam by a Cardiologist (Heart Doctor) Heart Catheterization or Angiogram Coronary Angioplasty (PTCA/Balloon/Stents) Exercise Stress Test (Treadmill) Echocardiogram (Ultrasound of the Heart) Pacemaker / Defibrillator Open Heart Surgery Place (hospital or city) Complications/ Problems

Social History Do you: Yes No Do you now or have you ever smoked tobacco products.. Cigarettes: # of packs per day: # of years: Cigars. Pipes.. When was you last cigarette, cigar or pipe? Do you have exposure to second hand smoke. Do you drink alcohol on a regular basis. If no, did you drink heavily in the past.. If yes, how much do you typically drink in one week Do you use recreational drugs. Have you ever been treated for substance abuse. Diet: Balanced Low fat low cholesterol Low salt No special diet Other, please describe: Activity Level: Exercise Strenuously on a regular basis Exercise moderately on a regular basis Exercise on an occasional basis which of the following best describes your level of physical activity both in your daily life and your leisure time Do not regularly exercise, but have an active lifestyle Have difficulty accomplishing light chores of daily living Require assistance to accomplish self-care Family History Relation: Age Age at Death Cardiac History Father Mother Sister Sister Brother Brother Please list which family members (blood relatives) have experienced these conditions Heart Attack: Aneurysm: Diabetes: Cancer: Sudden Death: High Blood Pressure: High Cholesterol: Heart Failure: Stroke: Arteriosclerosis: (Hardening of the arteries)

Review of Systems SKIN EAR/NOSE/THROAT Rashes, psoriasis or dermatitis Loss of hearing Non-healing sores or skin ulcerations Hearing aids? Skin Cancer Ringing in the ears. Frequent or severe nose bleeds EYES Frequent sinus infections Wear glasses Dentures Wear contact lenses Permanent blindness in either eye NERVOUS SYSTEM Cataracts Frequent headaches or migraines Glaucoma Epilepsy or seizures Date of last seizure: HEART Depression Heart attack, what year(s): Nervous disorder Chest discomfort/angina with physical activity Specify: Chest discomfort/angina at rest Shortness of breath with exertion CIRCULATION Shortness of breath at rest Discoloration of feet or legs Require more than one pillow at night to Pain in legs or buttocks with exercise breathe well Sores or ulcers on feet or legs Heart failure or fluid on lungs Blood clot in Artery Palpitations, racing or pounding heart beat Blood clot in leg vein Pauses in the heart beat Ankle or leg swelling Previously diagnosed heart rhythm Phlebitis of leg veins disturbance = arrhythmia Sudden visual disturbances in either eye Heart murmur Weakness or paralysis of one side of the body Mitral valve prolapse Temporary speech loss or difficulty talking Stroke BLOOD Mini-strokes or TIA s Bleeding or bruising tendency Dizziness, light-headedness or black out spells Blood disorder Aneurysm of any blood vessels Specify: Previous blood transfusion MUSCLES/BONES/JOINTS Recent fever Arthritis or other joint disease History of hepatitis or other communicable Curvature of the spine (scoliosis) disease Chronic back trouble STOMACH/INTESTINES Stomach ulcer or peptic ulcer Frequent heartburn or indigestion Liver disease or jaundice What year: Frequent diarrhea Chronic constipation Dark, tarry stools METABOLISM/ENDOCRINE Thyroid disorder Gout Recent weight gain or loss (> 10 lbs)

Review of Systems (continued) LUNGS Asthma or wheezing Recent bronchitis or chest cold Pneumonia Emphysema Tuberculosis Chronic cough Coughing up blood Exposure to asbestos Blood clot (embolus) to lungs Snoring KIDNEYS/URINARY TRACT Kidney disease or failure History of kidney dialysis What year: Kidney stones or infection Pain or burning with urination Dribbling or incontinence (difficulty holding urine) Multiple trips to bathroom to urinate at night Blood in urine during past year Enlarged prostate REPRODUCTIVE (for Women) REPRODUCTIVE (for Men) Are you or might you be pregnant? Have you had a vasectomy? Date (or year) of last Period Erectile Dysfunction? Do you have any natural children? How many deliveries Vaginal C Section Any problem with high BP during pregnancy? Any problem with blood sugar or diabetes with pregnancy? Did you ever take hormonal therapy? Date Doctor s Signature

If you are scheduled for surgery or a hospital stay, please answer the following question: Have you or a blood relative had any problems with Anesthesia? If yes, please describe: Do you have an advanced directive - living will, health care proxy, etc? If so, may we have a copy? Do you have any other special concerns or additional information we should be aware of regarding your care: I certify that the information provided in this form is correct to the best of my knowledge. I will not hold my doctor or any members of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. Patient Signature Date

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