New Patient Medical Information
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NEW PATIENT MEDICAL INFORMATION
Please PRINT and COMPLETE ALL SECTIONS Below
Name: _______________________________________
_____________________________________
____________
Last Name
First Name
Middle Initial
Date of Birth: _____ / _____ / _____ Pharmacy Name & Address: _______________________________________________
Insurance Policyholder Name: ______________________________________________
Insurance Policyholder Date of Birth: __________________
FAMILY HISTORY:
______________
Cancer
Heart Disease
Diabetes
Other:
SOCIAL HISTORY:
Marital status: ____________
Diet description: _________________________________________________________________________________________
Types of exercise:________________________________________________________________________________________
Number of exercise days per week:_________
Tobacco use?:
Yes
No
Alcoholic drinks per week: ________
PAST MEDICAL HISTORY:
Any current medical complaints? _____________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Any past medical history? ___________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
MEDICATIONS: List all medications and the dosage and number of pills you take per day. _____________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
DRUG ALLERGIES: List all medications to which you are allergic. _______________________________________________
________________________________________________________________________________________________________
SUPPLEMENTS: List all supplements that you are taking. _______________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
IMMUNIZATION HISTORY:
Childhood vaccinations up-to-date?:
Yes
No
Date of last TB shot (tuberculosis): ___________________
Date of last Td shot (Tetanus): ______________________
Date of last Pneumonia shot: ________________________
Date of last Flu shot: ______________________________
Date of last shot (Other): ___________________________
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