New Patient Information Form
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1
2NEW PATIENT INFORMATION FORM
Date: ________________________________________ Email:______________________________________________
Patient: _____________________________________ Referred by:_________________________________________
HISTORY
CHIEF COMPLAINT/HISTORY OF PRESENT ILLNESS
Date of last Mammogram:_______________________
Have you ever been diagnosed with breast cancer?
□ yes □ no
If known □ T1 □ T2 □ T3 □ ER positive □ PR positive
□ HER2 positive
Are you taking □ Tamoxifen □ Aromatse Inhibitor (Arimidex)
Date of last Colonoscopy (if over age 50)_______________
□ Do Not Receive
□ Receive annually
Flu Vaccine:
Estimated Date of last Vaccine___________________
MEDICAL HISTORY
●Patient MEDICAL history
Previous Hospitalizations/Surgeries/Serious Injuries
When?
Diabetes
No
Yes
_____________________________________________ ____________________________
Hypertension
No
Yes
Cancer
No
Yes
_____________________________________________ ____________________________
Stroke
No
Yes
Heart trouble
No
Yes
_____________________________________________ ____________________________
Arthritis/gout
No
Yes
●FAMILY medical history
Convulsions
No
Yes
Bleeding tendency No
Yes
______________________________________________________________________________
Acute infections
No
Yes
______________________________________________________________________________
Venereal disease
No
Yes
Hereditary defects No
Yes
______________________________________________________________________________
Night Sweats
No
Yes
________________________________________________________________
●Patient SOCIAL history
Marital Status:
□Single
□Married
□Separated
□Divorced
□Widowed
Use of Alcohol:
□Never
□Rarely
□Moderate
□Daily
Use of Tobacco:
□Never
□Previously, but quit
Current packs/day_______
Use of Drugs:
□Never
□Type/Frequency _______________________________
Excessive exposure at home or work to:
□Fumes
□Dust
□Solvents
□Airborne Particles
□Noise
●Medications and dosages
1)_________________________________________________________________________
2)_________________________________________________________________________
3)__________________________________________________________ _______________
4)_________________________________________________________________________
5)_________________________________________________________________________
6)_________________________________________________________________________
7)_________________________________________________________________________
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