New Patient Registration Form Page 5
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1
2
3
4
5
6
7
8–
N
P
H
F
EW
ATIENT
ISTORY
ORM
PAGE 2
N
:
AME
P
.
LEASE LIST ALL YOUR MEDICATIONS IN THE TABLE BELOW
MEDICATION NAME
PILL SIZE
TIMES TAKEN AND NUMBER OF P ILLS TAKEN
–
(
(
,
)
HOW MANY
EXAMPLE
TWO AT BREAKFAST
ONE AT DINNER
?)
MILLIGRAMS
(P
LEASE INCLUDE
,
HORMONE MEDICATIONS
,
BIRTH CONTROL PILLS
,
HERBAL MEDICINES
,
VITAMINS
DIET
,
-
SUPPLEMENTS
OR OVER
-
THE
COUNTER
MEDICINES THAT YOU
TAKE ON A REGULAR
.
BASIS
IF YOU NEED
,
MORE SPACE
PLEASE
ATTACH ANOTHER
.)
PAGE
H
AVE YOU HAD RECENT PROBLEMS WITH THE FOLLOWING?
Y N F
Y N F
ATIGUE
REQUENT URINATION
Y N W
G
Y N N
EIGHT
AIN
IGHTTIME URINATION
Y N W
L
Y N L
EIGHT
OSS
OW LIBIDO
Y N H
Y N H
EAT INTOLERANCE
OT FLASHES
Y N C
Y N A
(
)
OLD INTOLERANCE
BNORMAL PERIODS
WOMEN
Y N P
Y N P
(
)
OOR SLEEP
OOR ERECTIONS
MEN
Y N B
Y N J
LURRED VISION
OINT PAIN
Y N D
Y N M
/
OUBLE VISION
USCLE ACHES
PAIN
Y N H
Y N M
OARSENESS
USCLE WE AKNESS
Y N S
T
Y N R
ORE
HROAT
ASH
Y N C
Y N E
HEST PAIN
ASY BRUISING
Y N P
Y N H
ALPITATIONS
EADACHE
Y N S
Y N N
/
HORT OF BRE ATH
UMBNESS
TINGLING
Y N C
Y N D
OUGH
EPRESSED
Y N N
Y N A
AUSEA
NXIOUS
Y N V
Y N F
OMITING
ALLS
Y N D
IARRHEA
Y N C
ONSTIPATION
P
N
HYSICAN
OTES:
R
:
EVIEWED BY
D
:
ATE
Greater Houston Diabetes & Endocrinology Center (GHDE)
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