New Patient Medical History Form Page 2
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1
2
3Name:__________________________________ Date of Birth:_________ Today’s Date:___________
Social History:
Alcohol use -
Never
Occasionally
Daily
Type____________________________________________
Tobacco use -
Never
Previously, but quit
Packs Per Day________ for _______ years
Drugs use -
Never
Occasionally
Daily
Type____________________________________________
What is your occupation?____________________________________________________________________________________
Marital Status:
Single,
Married,
Divorced,
Widowed,
Separated
Name of spouse or significant other ___________________________________________________________
Children:
Number of Children______ Number of grandchildren______
Women:
Number of pregnancies______ , Number of deliveries______ - Vaginal______, C-sections______,
Miscarriages______, VIPs (abortions) ______
Cancer health habits:
(Circle response)
Women
Men
Breast:
Monthly self-exam
Y
N
Prostate:
Yearly rectal exam
Y
N
Yearly physician exam
Y
N
Yearly PSA blood test
Y
N
Last mammogram
Y
N
GYN:
Yearly GYN exam
Y
N
Yearly PAP exam
Y
N
All
Colon:
Yearly rectal exam
Y
N
Skin:
High sun exposure
Y
N
Yearly stool test for blood
Y
N
Yearly skin exam
Y
N
Date of last colonoscopy ______________
Review of Systems:
Do you currently have any of the following symptoms or conditions (Check if yes)
General:
Nothing in this group
Cardiovascular:
Nothing in this group
Weight loss – How much ______lbs
Chest pain
Loss of Appetite
Palpitations
Fever
Heart valve problems
Chills
Calf pain with walking
Night Sweats
Leg swelling
Fainting Spells
Respiratory:
Nothing in this group
Eyes:
Nothing in this group
Chronic cough
Eye disease or injury
Coughing up blood
Wear glasses or contacts
Short of breath with activity
Blurred or double vision
Short of breath lying flat
Ear, Nose, Mouth, Throat:
Nothing in this group
Wheezing
Hearing loss
Asthma
Ear ache / infection
Bronchitis
Ringing in ears
Pneumonia
Nose Bleeds
Musculoskeletal:
Nothing in this group
Bleeding gums
Joint pain
Mouth sores
rthritis
Sore throat
Back pain
Recent voice change
Muscle weakness
Runny nose / cold
Leg pain with walking
Sinus problems
Leg pain at rest
Neck stiffness / pain
Broken bones _______________________
Enlarged neck glands / masses
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