Patient Assessment Form (New Patients Only) Page 2

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NAME____________________________________ 
MRN# ______________________ 
Personal/Family History
 (Check all that apply for patient and/or family member) 
IF YES 
PATIENT/HOW OFTEN
FAMILY MEMBER/HOW OFTEN
 ________________________
 ________________________
Allergies 
 ________________________
 ________________________
Amputation 
Anesthesia Problems 
 ________________________
 ________________________
 ________________________
 ________________________
Angina 
 ________________________
 ________________________
Anxiety or Depression 
 ________________________
 ________________________
Asthma 
 ________________________
 ________________________
Bleeding/Bruising Problems 
 ________________________
 ________________________
Bowel Problems 
 ________________________
 ________________________
Cancer 
 ________________________
 ________________________
Chest Pain/Heart Disease 
 ________________________
 ________________________
Diabetes Mellitis 
 ________________________
 ________________________
Dizziness 
 ________________________
 ________________________
Ear Problems 
 ________________________
 ________________________
Eye Problems 
 ________________________
 ________________________
Headaches 
 ________________________
 ________________________
Heartburn 
 ________________________
 ________________________
Hepatitis 
 ________________________
 ________________________
High Blood Pressure 
 ________________________
 ________________________
Hyperthermia/Hyperpyrexia (malignant) 
 ________________________
 ________________________
Kidney Disease 
 ________________________
 ________________________
Known Genetic Disorder 
 ________________________
 ________________________
Mental Retardation/Illness 
 ________________________
 ________________________
Moles that are changing 
 ________________________
 ________________________
Nasal Problems 
 ________________________
 ________________________
Pain in Joints/Limbs 
 ________________________
 ________________________
Persistent Cough/Wheezing 
 ________________________
 ________________________
Prostate Enlargement 
 ________________________
 ________________________
Rashes, Sores, Itching 
 ________________________
 ________________________
Ringing in Ears 
 ________________________
 ________________________
Seizure Disorder 
 ________________________
 ________________________
Shortness of Breath 
 ________________________
 ________________________
Skin Problems 
 ________________________
 ________________________
Stroke 
 ________________________
 ________________________
Thyroid Problems 
 ________________________
 ________________________
Trouble Sleeping 
 ________________________
 ________________________
Tuberculosis/Lung Disease 
 ________________________
 ________________________
Stomach/Leg Ulcers 
 ________________________
 ________________________
Urination Problems 
 ________________________
 ________________________
Weakness/Numbness 
 ________________________
 ________________________
OTHER ____________________ 
  CHECK IF NONE APPLY   
 ________________________
 ________________________
Personal/Social History
  
Residence  
Nursing Home      Private Home    Live Alone    Apartment   Shelter   
Other _________    
Who wil assist in your care?    Spouse   Family  Friend  Self    Other (Name and Phone)
Do others depend on you for their care?
No
Yes
N/A
Are you currently in a domestic violence situation?    No      Yes  
COMPLETED BY: _________________________________ DATE: ___________ 
REVIEWED BY: ______________________ID # _________ DATE: ___________ 
v.10/20/150C

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