New Patient History Form
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1New Patient History
Date:_______________
Your Medical History:
Name:_____________________________________
High blood pressure
High cholesterol
Seizure
Age__________ Primary MD :_______________
Asthma
Heart disease
Hypothyroid
Hyperthyroid
Insurance_________________________
Lung DZ
Heart attack
Liver problems
Hepatitis
Required Lab: Labcorp
Quest
LabOne
Renown
Migraines
DVT (blood clots) Bleeding disorder
Stroke
Required Radiology____________________________
Diabetes: AODM or IDDM
Depression/anxiety
ALLERGIES to medications:______________________
Cancer: What kind?______________________________________
_________________________Allergy to Latex: Y
N
OTHER
ILLNESS___________________________________________
MEDICATIONS: _____________________________
___________________________________________
Family History
Social History
__________________________________________
Problem
Relationship:
Habits:
__________________________________________
Tobacco: None
Quit
High blood
REASON FOR VISIT:___________________________
Yes: How many?________
pressure
___________________________________________
Alcohol: Never Social
Stroke
Gynecologic History: Please circle or complete:
Recovering
Heart Dz
st
Gyn
None
1
day of last period________________
________________________
DVT/Blood
Last pap__________ Last mammo______
Marital Status: Single
clots
Last colonscopy?_____________________
Married Divorced Widowed
Diabetes
Type of birth control?____________________
Steady partner
Cancer:
Menses
None
Regular Irregular Severe cramping >7days
Occupation:
Breast
st
Excess bleeding Age of 1
period?__________
_________________________
Ovarian
STD/Inf
None
Warts/condyloma
HPV
Herpes
ection
Uterine
Chlamydia
Gonorrhea
PID
Colon
Other
None
Endometriosis
Ovarian cysts
Fibroids
history
Other:
PMS
DES exposure
Pain w/sex
Osteoporosis
Bleeding w/sex
Falling out feeling/pressure
Menop
None
Hot flushes Night sweats
Vaginal dryness
REVIEW: Circle CURRENT PROBLEMS ONLY.
Pap
Normal
Never
Abnormal
HPV
Dysplasia
Smears
Colposcopy Cryo Laser Leep
Cone biopsy
Urinary
None
Incontinence
Frequency
Urgency
st
Sexual
Never
Age of 1
intercourse_______
Blood in urine
Pain w/urination
history
Sexual Preference:
Male
Female
Number of partners: <5
>5
Falling out feeling
Incomplete emptying
OB
None
# of preg ______ # of deliveries________
Breast
None
Pain
Discharge
Lump
history
# of miscarriage _____# of abortions _______
C-sections
Complications
GI
None
Nausea/vomiting
Abd. Pain/cramping
Diarrhea
Constipation
Surgical History: What surgeries have you had?
Bloody/black stools
Bloating
Tonsillectomy
GYNECOLGIC: Hysterectomy: Vaginal
Other
None
Unexplained weight gain
Fatigue
Breast biopsy
Abdominal Laparoscopic
Headaches
Fainting
Wt loss
Appendectomy
Ovaries removed:
D&C/hysteroscopy
Gallbladder
Ovarian cyst removed Laparoscopy
Other
comments:______________________________
Bladder repair
Tubal ligation
C-section
_______________________________________
Orthopedic
Cosmetic
Other:_____________________
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