New Patient & Medical History Form Page 3

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 Yes  No
 Full time
 Part time
 Retired
Are you employed?
If yes:
Have you had any of the following immunizations? If yes, include last year you had the immunization.
Year
Year
Year
Year
 Tetanus
 Flu Shot
 Pneumococcal
Hepatitis B
Have you had any of the following tests? If yes, include last year you had the test.
Year
Year
Year
Year
 EKG
 Stress Test
 Colonoscopy
Mammogram
Check any symptoms and or conditions listed below that you have experienced in the past 12 months:
 Change in far vision  Change in near vision  Blurred Vision
Vision:
 Ear pain  Loss of Hearing  Ringing in Ears
Hearing:
 Joint Pain  Joint Stiffness  Muscle weakness  Unsteady Walking
Musculoskeletal
 Chest pain  Palpitations
Cardiovascular
 Shortness of breath  Wheezing  Coughing  Coughing up blood
Respiratory:
 Swelling of the Hands/Feet  Leg Cramps with walking
Circulatory:
 Excessive thirst  Frequent urination  Unintentional Weight Change > 5 lb.
Endocrine:
 Diarrhea  Constipation  Blood in stools  Heartburn
Gastrointestinal
 Headaches  Numbness or tingling in extremities
Neurological
 Depression  Anxiety
Emotional:
I attest that this information is correct to the best of my knowledge.
______________________________
X
________
Patient Signature
Date
X ______________________________
________
Reviewed by Clinician’s Signature
Date

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Parent category: Medical
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