New Patient/existing Patient Update Questionnaire Form printable pdf download

TRIANGLE FAMILY CARE, P.A.

New Patient/Existing Patient Update Questionnaire

(CONFIDENTIAL)

Date Completed: ___________________ Name: ______________________ DOB: _________________

Please circle any medical problems that you have now or have had:

Diabetes, high blood pressure (hypertension), asthma, allergies, depression, anxiety, thyroid problems,

arthritis, HIV, migraines, anemia, high cholesterol, cancer (please specify: ______________________)

Please list any other medical problem not listed above that you have now or have had:

______________________________________________________________________________________

Please list any surgeries you have had and the year you had the surgery, if you know it:

______________________________________________________________________________________

Please list all medications that you take and the dosages and frequency (please include prescribed

and over-the-counter medicines, including vitamins, minerals and herbs):

______________________________________________________________________________________

Please list any allergies to medications and list non-mediation allergies as well:

______________________________________________________________________________________

From what country or area of the country (i.e. state) are you? _________________________________

What is/was your occupation?: ___________________________________________________________

Do you exercise regularly? (circle) Yes No If yes, how often and what form of exercise? _________

Do you now smoke? (circle): Yes No If yes, how many per day? ____ and for how many years? __

Did you ever smoke? (circle): Yes No If yes, when did you quit? _____________

Do you drink alcohol? (circle): Yes No If yes, on average, how many drinks per week? _______

Do you drink caffeine? (circle): Yes No If yes, on average, how many drinks per day? ________

Do you currently use any drugs like marijuana or cocaine? (circle): Yes No If yes, please explain to the doctor.

Marital Status: Are you (circle all that apply): single, married, widowed, divorced, separated

If married, what is your spouse’s name: ______________________________

If single, widowed, divorced or separated, do you have a significant other (boyfriend/girlfriend)?: Yes No

List the names of your children (if any): ___________________________________________________

How do you describe your gender? (circle): Male, Female, Transgender (MTF or FTM), Non-binary

How would you describe your sexual orientation? (circle): heterosexual (straight), homosexual (gay),

bisexual, asexual, don’t know, prefer to discuss in person with provider

Do you observe a particular religion or faith? (circle): Yes No If yes, please name: _______________

Do you feel safe at home (please circle)? Yes No Prefer to discuss in person with provider

Do you have:? (please circle all that apply): Living Will, Healthcare POA, MOST form, DNR form

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New Patient/existing Patient Update Questionnaire Form