New Patient Information Survey
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1
2New
P atient
I nformation
S urvey
Revised 9/2010
We are glad you chose the Augusta Surgical Group to meet your surgical needs. Please take a few minutes
to fill out this form, as it will help us provide you with optimal care. Please circle choices or fill in blanks
where appropriate. Thank you for your time.
Name: _____________________________ Date of Birth:
Today’s Date: ______________
Age: ______
Sex: M / F
Home Phone: _________________
Cell/Work Phone: __________________
Primary Medical Doctor:____________________
Referring Doctor: _________________________________
Other Doctors & their specialites:________________________________________________________________
What brings you to the office today:
Leave blank for MD:
Recent Test Results:
Last mammogram: __________________________
Last colonoscopy: __________________________
Do you currently or have you recently had any of the conditions listed below? Please Circle N for No or Y for Yes
General
Cardiovascular
Genitourinary
Weight Loss
N
Y
Irregular heart beat
N
Y
Urinary frequency
N
Y
Fever
N
Y
Chest Pain
N
Y
Urinary urgency
N
Y
Fatigue
N
Y
Fainting
N
Y
Voiding at night
N
Y
Weakness
N
Y
Do you get short of breath with
Night sweats
N
Y
lying flat?
N
Y
Neuro/Psych
Varicose Veins
N
Y
Headaches
N
Y
Ear/Eye
Numbness
N
Y
Dizziness
N
Y
Gastrointestinal
Memory Loss
N
Y
Difficulty hearing
N
Y
Abdominal Pain
N
Y
Anxiety
N
Y
Change in vision
N
Y
Indigestion
N
Y
Depression
N
Y
Reflux
N
Y
Nose/Throat/Neck
Nausea
N
Y
Dermatologic
Hoarseness
N
Y
Vomiting
N
Y
Rash
N
Y
Masses
N
Y
Diarrhea
N
Y
Skin lesion
N
Y
Constipation
N
Y
Respiratory
Blood in stool
N
Y
Hematology
Short of breath
N
Y
Easy bruising
N
Y
Cyanosis
N
Y
Easy bleeding
N
Y
Wheezing
N
Y
Swollen lymph nodes N
Y
Medical Conditions (Please circle those that apply)
*Asthma
*Oxygen/Inhaler use
*Bleeding Disorder
*Blood Clots
*Cancer
*Cardiac Arrest
*Stroke
*Diabetes
*Hepatitis
*HIV/AIDS
*High Cholesterol
*High Blood Pressure
*MRSA *Kidney Disease
*Seizures
*Thyroid disease
*Others: __________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Surgical History: (List all operations and approximate dates)
*Cardiac Catheterization
*Hernia
*Pacemaker
*Others: ______________________________________________________________________________________
_____________________________________________________________________________________________
Family Medical History: (List medical conditions affecting your immediate family)
Mother-
Father-
Siblings-
Children-
Augusta
S urgical
G roup,
P .C.
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