New Patient History Form Page 3
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7NEW PATIENT MEDICAL HISTORY FORM
______________________
Patient Name: ___________________________________________________ MRN#
Past Surgical History: (Please circle and date any of the surgeries and/or procedures that you have undergone)
Coronary Bypass
Date:__________________
Knee Replacement
Date: ___________________________
Angioplasty
Date:__________________
Rotator Cuff Repair
Date: ___________________________
Pacemaker
Date:__________________
Cataract
Date:____________________________
Cardiac Valve surgery Date:__________________
Gallbladder surgery
Date:____________________________
Hemorrhoidectomy
Date:__________________
Hysterectomy
Date:____________________________
Prostate Operation
Date:__________________
Prostatectomy
Date:____________________________
Hernia Repair
Date:__________________
Appendectomy
Date:____________________________
Tonsillectomy
Date:__________________
Hip Replacement
Date:____________________________
Mastectomy
Date:__________________
Lumpectomy
Date:____________________________
Other Operations:_____________________________________
Social History:
Tobacco Use: (Present &/or Past):
Never Smoked
Quit smoking When? ________ How many years did you smoke? ______yr(s) How many packs? ______/day
Currently Smoke
Cigarettes
Pipe
Cigars How many packs? _____/day How many years?_________
Chewing Tobacco
Alcohol History: (Present &/or Past):
Non Drinker
Beer
number of bottles _________ per
Day
Week
Month
Wine
number of glasses _________ per
Day
Week
Month
Liquor number of glasses _________ per
Day
Week
Month
Are you:
Employed/Self Employed
Unemployed
Retired
Disabled
(Former) Occupation:______________________________________________________________________________
Name of Employer:___________________________________________ Work Phone: (______)__________________
Marital Status:
Married
Single
Widowed
Divorced
Other
Lives Alone
Lives with Family
Lives in Nursing Home
Winter Resident
Year Round Resident
Children:
Yes
No
Number____________________________________________
Health Maintenance:
Sigmoidoscopy / Colonoscopy:
Yes
No
Date:_____________________________________________________
Findings:__________________________________________________
Last Mammogram: Date: ___________ Last Bone Density: Date: ___________ Last Pelvic Exam: Date _____________
Influenza (Flu) Shot: Date : __________ Pneumococcal Shot: Date : _________ Last Shingles Shot: Date : ___________
Last EGD: Date:___________________
Family Medical History: Indicate any family members with cancer, blood disease or other disease
Age
Disease
If deceased, cause of death
Father:
____________
________________________
___________________________________________
Mother: ____________
________________________
___________________________________________
Siblings: ____________
________________________
___________________________________________
____________
________________________
___________________________________________
____________
________________________
___________________________________________
In your opinion, are there any diseases that run in your family?
Yes
No
Please list:________________________________________________________________________________________
____________
Patient’s Initials
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