New Patient Intake Form Page 2
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2Weill Cornell Medical College
Name:____________________________
Department of Obstetrics and Gynecology
MRN:____________________________
Division of Maternal Fetal Medicine
Date of visit: ______________________
Medications: (List names and dosages; include vitamins, herbs, and other supplements):
Medication
Dosage
How Often
Medication
Dosage
How Often
Past and Current Medical History (Please include year if diagnosis and treatment were given).
____________Anemia (Blood Transfusion?)
___________________Hemorrhoids
____________________Neurologic Disorder
_______________Anesthesia Complications
__________________ Hiatal Hernia
____________________Psychiatric Disorder
_________________________Breast disease
_________________Kidney Stones
________________Seizure Disorder/Epilepsy
_______________Congenital Heart Problem
___________Lung Disease/Asthma
______________________Sickle Cell/Carrier
_____________________________Diabetes
________________________Lupus
_______________________TB/ Positive PPD
_______________Gastrointestinal/Gallstones
_____________Migraine Headaches
________Thrombotic Disorder (Blood Clots)
Surgical History (Briefly include your surgical history).
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Family History
Mother: Living:
Deceased (Cause) :
Father: Living
Deceased (Cause):____________________________
Siblings Number Living:
Number deceased:
Cause__________________________________________________
Detail below if anyone in your immediate family had the diagnosis: (Please indicate Mother, Father, Sibling, Grandparents and which side).
___________________________
______________________
____________________________
______________________
Bleeding Disorder
Cancer-Other
High Blood Pressure
Neurological Disease
____________________________
______________________
____________________________
______________________
Blood Clots
Diabetes
High Cholesterol
Psychiatric Disease
___________________________
_______________________
___________________________
_______________________
Cancer: Breast/GYN
Heart Disease
Multiple Pregnancy
Thyroid Disease
Other__________________________________________________________________________________________________________________
Social History
Occupation:
Marital Status:
Do you smoke?
If so, how many packs a day?
Do you drink alcohol? No Yes
If so, how many drinks/week?
Do you take drugs?
If so, which ones?
Review of Systems: Are you experiencing any of the following symptoms? Please indicate all that apply or NO if they do not.
_____Fatigue
_____Fever
Constitutional
No
Weight Loss
Weight Gain
_____
_____
_____Vision Changes
Eye Problems
No
Glasses/Contacts
_____
Ear, Nose,
No
_____Headache
Sinusitis
Ringing in
Nose Bleed
_____
_____
_____
Ears
Throat
Cardiovascular
No
Shortness of Breathe
Chest Pain
Edema
Palpitations
_____
_____
_____
_____
Respiratory
No
Wheezing
Coughing Blood
Cough
_____
_____
_____
Gastrointestinal
No
Nausea/vomiting
Constipation
Diarrhea
Bloody
_____
_____
_____
_____
Stool
Genitourinary
No
Bloody Urine
Painful Urination
Urgency
Frequency
_____
_____
_____
_____
Musculoskeletal
No
Muscle Weakness
Muscle Pain
_____
_____
No
Breast Pain
Nipple Discharge
Breast Mass
Skin Rash
Skin/Breast
_____
_____
_____
_____
Neurological
No
Fainting
Seizures
Numbness
Trouble
_____
_____
_____
_____
Walking
Psychiatric
No
Depression
Anxiety
_____
_____
Endocrine
No
Dry skin
Abnormal Thirst
Hot Flashes
_____
_____
_____
No
Easy Bruising
Abnormal
Swollen
Blood/Lymph
_____
_____
_____
Bleeding
Glands
Other ___________________________________________________________________________________________________
Reviewed By:_______________________________________________________________, MD on ______________________
Date
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