New Patient Information Form - Trauma And Acute Care

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TRAUMA AND ACUTE CARE
FRONT
Name: _____________________________________ DOB: __________ Patient Age: _______ Today’s Date: __________
Physician: _____________________________________ Referring Physician: ___________________________________
What are we seeing you for today? ________________________________________________________________________
What symptoms are you having? _________________________________________________________________________
Name of your preferred pharmacy? ________________________________________________________________________
Surgical History:
Have you ever had a colonoscopy?
o Yes
o No
When? _________________
Have you had any operations in the past?
o Yes
o No
If yes, please list: ___________________________________________________________________________________
Medical History: (Please check any applicable)
o Aneurysm
o Pneumonia
o Peptic Ulcer Disease
o Heart Attack
o COPD
o Kidney Stones
o High Blood Pressure
o Asthma
o Thyroid Disease
o Stroke
o Lung Cancer
o Prostate Cancer
o Congestive Heart Failure
o Tuberculosis
o Breast Cancer
o Mitral Valve Prolapse
o Hepatitis A, B, C
o Skin Cancer
o High Cholesterol
o Cirrhosis of he Liver
o Depression
o Colon Cancer
o Hiatal Hernia / GERD
o Seizures
o Colon Polyps
o Diabetes: o Type I o Type II
Other problems not listed: _______________________________________________________________________________
Do you take:
Aspirin: o Yes o No Arthritis Medication: o Yes o No Coumadin (Warfarin): o Yes o No Plavix: o Yes o No
If yes, please List Medications along with Dosage:
Are you taking any medications daily? o Yes o No
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Are you allergic to any medications? o Yes o No
Are you allergic to any Latex? o Yes o No
If yes, please list along with reactions: ___________________________________________________________________
____________________________________________________________________________________________________
Family History:
Mother:
o Alive
o Deceased
Cause of death: _____________________________________________________
Father:
o Alive
o Deceased
Cause of death: _____________________________________________________
Any family history of: (Immediate Family)
Cancer:
o Yes
o No
If yes, please list relation and type of cancer: ______________________________________
Diabetes:
o Yes
o No
If yes, relation: _____________________________________________________________
Strokes:
o Yes
o No
If yes, relation: _____________________________________________________________
Heart Attacks: o Yes
o No
If yes, relation: _____________________________________________________________
Social History:
o Married
o Divorced
o Widowed
o Single
# of Children: __________
Occupation: _____________________________________________________________
Tobacco History:
o Current Use
o Previous Use
o Never Used
# of years used: ______ # of years quit: ______
Alcohol Use:
o Yes
o No
If yes, frequency: ___________________________________________________________
FORM # NGPG 505001-03092 (3/7/16)

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