New Patient Health History Form
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7Medicine In Balance
New Patient Health History Form
General Informati on
Name ________________________________________________________________________
Street Addre ss __________________________________________________________________
City
___ ___ ____ ___ ___ ___ ____ ___ ___ _
State
_____ __
Zi p
___ ____ ___ ___ ___ ____ __
Telep hone ( day)
_ ___ ____ ___ __
(even ing)
_ _ ____ ____ ___ ___
(cell )__ ___ ___ ____ ___ ___
Email A ddre ss
___ ___ ____ ___ ___ ___ ____ ___ __ ____ ____ ___ ___ ___ ____ ___ ___ ___ ____ ___ _
Birth Da te
____ ___ ___ ____
Age __ ___ ___ _ S ocial Secur ity N u mber _ ___ ___ ____ ___ ___ __
Pri mar y Ph ysicia n’ s Na me: _ ____ ___ ___ ___ ____ ____ ____ ___ ___ Pho ne__ ___ ____ ___ ___ ___
Emerge ncy Co ntact Na me:
__ ___ ___ _ ___ ___ __ ____ ____ ___ ___
Pho ne___ ___ ___ ___ ____ __
Reaso n for Today’ s Visit : ___ ____ ___ ___ ___ ___ ____ ____ ___ ___ ___ ____ ___ ___ ___ ____ ___ __
Please li st all p resc riptio n me dication s an d do sage s: ___ ___ ___ ___ ____ ___ ___ ___ ____ ___ ___ _
Inst ructio ns:
____ ____ ___ ___ ___ ____ ___ ___ ___ ____ ___ ___ __ ____ ____ ___ ___ ___ ____ ___ ___ ___ ____ ___ __
Answer all
items to the
____ ____ ___ ___ ___ ____ ___ ___ ___ ____ ___ ___ __ ____ ____ ___ ___ ___ ____ ___ ___ ___ ____ ___ __
best of your
knowledge.
Medical History
For additional
space, use
“Additional
In general how would you describe your health?
[ ] Excellent [ ] Good [ ] Fair [ ] Poor
Comments” on
page 4.
Do you have any heart conditions?
[ ] Yes [ ] No
Describe: ______________________________________________________________________________________
Have you ever had high blood pressure?
[ ] Yes [ ] No
Have you ever had your cholesterol level tested?
[ ] Yes [ ] No
If Yes, what were the results? ______________________________________________________________________
Do you have asthma, chronic bronchitis, emphysema, or other lung condition?
[ ] Yes [ ] No
Describe: _____________________________________________________________________________________
Do you have diabetes? [ ] Yes [ ] No
If Yes, specify Type: [ ] Type 1 [ ] Type 2
If so, how is it controlled? ________________________________________________________________________
Do you have any stomach/bowel disorders?
[ ] Yes [ ] No
Please explain: _________________________________________________________________________________
Have you ever had cancer?
[ ] Yes [ ] No
If so, what type and when was it diagnosed? _________________________________________________________
Please describe any other significant medical history:___________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
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Parent category: Medical