Patient Assessment Form (New Patients Only)
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1
2PATIENT ASSESSMENT FORM (new patients only)
Patient Information
HGT
WGT
SS#
Name (Last, First, MI)
DOB
Gender Male Female
Home Phone
Cell Phone
Occupation
Work Phone
Religion
Race/Ethnicity
Preferred Lanaguage
Interpreter? No Yes
Name of Pharmacy
Location
Phone
Reason for Visit:_______________________________________________
Do you have any pain related to your presenting complaint/condition?
No
Yes
(If yes, Pain Tool must be completed)
Social Habits N/A
Cocaine No Yes
Narcotics/Drug Use No Yes
Alcohol No
Yes (frequency)_________
If Yes, # of Yrs _____ # of Packs/Day_____ When Stopped_____________
Smokes Tobacco No Yes
Is your child or others exposed to second hand smoke inside or outside of home? No Yes
Current Health Care Proxy No Yes
Living Will No Yes
Cultural & Religious Beliefs that May Affect Care No Yes _________________________________
Do you prefer to learn by Seeing (TV, Video, Written) Hearing (Audio) Doing (Hands On)
Do you have any barriers to learning (please check) Physical Emotional Vision Financial
Hearing Cognitive
What is your first language? _________________
Can you read and understand English? No Yes
Hospitalization/Surgery/Major Illness N/A
PROBLEM
YEAR
WHERE TREATED
DAYS IN HOSPITAL
Blood Transfusion No
Yes Date: ____________ Complications:
N/A
Gynecologic/Obstetric History
How many children have you given birth to?________
Any Pregnancies? No Yes (how many)
Going through menopause? No Yes
How many abortions/miscarriages? _____ _____
Date of last period ___________
Monthly breast exams? No Yes
Date of last mammogram: ___________
Lumps on breasts? No Yes
Medications
(Please list all medications you are currently taking, including vitamins and supplements)
1. _____________________________
6. _____________________________
2. _____________________________
7. _____________________________
3. _____________________________
8. _____________________________
4. _____________________________
9. _____________________________
5. _____________________________
10. _____________________________
Herbal medications?
Previous Bleeding Problems?
No Yes
No Yes
Allergies to Medication? No
Yes (type of reaction) _________________________________________
Food Allergies? No Yes (please specify) __________________________________________
Nutritional Data
Are you following a special diet? No Yes _______________________
Unintentional Weight
Over/Under 5 lbs in 1 month
Over/Under 10 lbs in 3‐6 months
Appetite Good (eat 3+ meals/day)
Fair (1‐2 meals/day) Poor (less than 1 meal/day)
v..10/10.20/150C
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