Patient Interview Form
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Complete Patient Interview Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
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4Patient Interview Form
Patient Information
First Name: ______________________ Last Name: ______________________ Date of Birth: __________ Today’s Date: __________
Email: ______________________________________________________________________________________________________
Reminder Preference
I would like to receive preventive care and follow up care reminders.
Yes
No
Allergies
Patient has no known allergies
Patient has no known drug allergies
Penicillins
Demerol
Fentanyl
Latex
Versed
Propofol
Sulfa
Eggs
Iodine
Other: _________________
Past or Present Medical Conditions
None
Neurology:
Stroke
Seizures/Epilepsy
Dementia
Parkinson’s
Endocrine:
Osteoporosis
Elevated cholesterol
Thyroid disorder
Diabetes
Cardiac:
Heart attack
Atrial fibrilation
Congestive heart failure
High blood pressure
Lungs:
Asthma
COPD
Valley fever
Sleep apnea
Gastrointestinal:
Barrett’s esophagus
Colon polyps
Diverticulosis
Pancreatitis
GERD
Colon cancer
Irritable Bowel Syndrome
Cirrhosis
Stomach ulcer
Ulcerative colitis
Lactose intolerance
Hepatitis B
H. pylori
Crohn’s disease
Celiac sprue
Hepatitis C
Urinary:
Enlarged prostate
Prostate cancer
Kidney stones
Kidney failure
Rheumatology:
Fibromyalgia
Lupus
Rheumatoid arthritis
Blood:
Bleeding disorder
Anemia
Lymphoma
Leukemia
Psychiatric:
Anxiety disorder
Depression
Bipolar disorder
Schizophrenia
Circulation:
Deep vein thrombosis
Pulmonary embolus
Peripheral vascular disease
Carotid artery disease
Cancer:
Cancer (type)
Any conditions not listed:
Other: __________________________________________________________________________________________________
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Parent category: Business