New Patient History Form
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PRAIRIESTAR HEALTH CENTER
New Patient History Form – Adult
Primary Care – Urgent Care – Industrial Medicine
Name: ____________________________ Today’s Date: __________________ Marital Status: M/D/S/W
Age: ________ Date of Birth: _____________ Occupation: _______________________________________
Reason for visit: ___________________________________________________________________________
Primary Care Provider: ______________________
Preferred Pharmacy:
Specialists you are currently seeing: ____________________________________________________________
Current Medications and Dose:
Medication Allergies:
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
List all surgeries and year:___________________________________________________________________
__________________________________________________________________________________________
Past and present medical problems (please check and describe):
CARDIOVASCULAR
EENT
ENDOCRINE
__ High Blood Pressure
__ Cataract
__ Thyroid Disease (hypo, hyper)
__ Heart Attack
__ Glaucoma
__ Diabetes
__ High Cholesterol
__Vision Problem
__ Osteoporosis
__ Heart Disease:_____________
__ Hearing Problem
__ No Problems
__ No Problems
__ Sinusitis/Allergies
PULMONARY
GASTROINTESTINAL
__ Dentures, teeth implants
__ Asthma
__ Acid Reflux, GERD
__ No Problems
__ COPD/emphysema
__ Diverticulosis
INFECTIOUS DISEASE
__ No Problems
__ Colon Polyps
__ History of Chicken Pox
RHEUMATOLOGY
__ Hemorrhoids
__ History of Tuberculosis
__ Arthritis
__ Liver Disease: ____________
__ HIV
__ Gout
__ Irritable Bowel
__ Hepatitis (A, B, C)
__ Rheumatism
__ Hernia: __________________
__ No Problems
__ Fibromyalgia
__ Bowel Disease: ____________ NEUROPSYCHIATRIC
__ No Problems
__ No Problems
__ Anxiety
__ CANCER Type: __________
GENITOURINARY
__ Depression
Date:_______________________
__ Urinary Incontinence
__ Mood Disorder: _____________
__ Prostate Enlargement
__ Seizures
Treatment:__________________
__ Gynecological Disease (uterus, __ Memory Problem
Oncologist:__________________
cervix, ovaries): ______________ __ Migraine
OTHERS NOT LISTED
__ STD: ____________________ __ Neuropathy
____________________________
__ Kidney Disease: ___________
__ Stroke
____________________________
__ No Problems
__ No Problems
____________________________
____________________________
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