New Patient Information Survey Page 2

ADVERTISEMENT

 
 
New   P atient   I nformation   S urvey  
Social History: Occupation: _____________________
Married / Single / Divorced / Widowed
Please describe current and previous use of the following substances:
Tobacco:
•
Current smokers: Average packs per day ____ Number of years smoked ____
o
Former smokers: Year quit _____ Number of years smoked ____ Average packs per day ____
o
Never ____
o
Alcohol: average # of alcoholic drinks per week _____
•
Caffeine: average # of caffeinated drinks per day _____
•
Ob/Gyn History:
Date of last menstrual period _______
Do you think you may be pregnant? _______
Age at first period ___
Age at first delivery____
Number of pregnancies___
Number of deliveries ___
•
Did you have: natural menopause, hysterectomy, or still menstruating?
(please circle one)
•
Describe hormone or birth control pill use: ________________________
Did you ever breast feed? Y / N
•
Describe previous breast biopsies : _________________________________________________________
•
Allergies: (List Drugs, Food, Tape, Latex/Rubber products and specific reactions) ___________________________
_____________________________________________________________________________________________
Medications that you are currently taking:
1. ____________________ 6. ____________________ 11. ____________________ 16. ____________________
2. ____________________ 7. ____________________ 12. ____________________ 17. ____________________
3. ____________________ 8. ____________________ 13. ____________________ 18. ____________________
4. ____________________ 9. ____________________ 14. ____________________ 19. ____________________
5. ____________________ 10. ____________________ 15. ____________________ 20. ____________________
Do you have any special needs/religious practices you would like us to be aware of?
Yes / No
If yes, please describe: __________________________________________________________________________
Patient Signature and Date: __________________________________
_____________________________________________________________________________________________
For office staff use only: Temp_____
HR_______
BP________
Ht______
Wt_____
PE:
A/P:
Physician Signature and Date: I have reviewed this ROS, SH, FH, PMH _________________________________
Augusta   S urgical   G roup,   P .C.  
Page   2  

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

New Patient Information Sheet New Patient Information Sheet Medical
New Patient Information Form New Patient Information Form Medical
New Patient Information Alyeska Family Medicine New Patient Information Alyeska Family Medicine Medical
New Patient Information Insurance Authorization And Assignment New Patient Information Insurance Authorization And Assignment Medical
New Patient Information Sheet New Patient Information Sheet Medical
New Patient Information Sheet New Patient Information Sheet Business
New Patient Information Form New Patient Information Form Medical
New Patient Information Form New Patient Information Form Medical
New Patient Information Form New Patient Information Form Medical
New Patient Information Form - Trauma And Acute Care New Patient Information Form - Trauma And Acute Care Medical

Related Categories

Parent category: Medical
Download
Go
Page of 2