New Patient History Form PDF Details

When visiting a new healthcare provider, patients are usually required to complete a New Patient History Form. This comprehensive document serves as a crucial tool for medical staff to gather extensive information about the patient's health background, including personal and contact details, marital status, emergency contacts, previous and current physicians, preferred local pharmacy, and referral source. It also inquires about allergies to medications, x-ray dyes, or other substances, which is paramount for ensuring patient safety during treatments. Furthermore, the form covers an exhaustive review of systems, asking the patient to indicate any past or current medical issues spanning from common conditions like high blood pressure and diabetes to more specific concerns such as skin diseases, venereal diseases, and mental health disorders. Women are asked to provide additional details regarding their reproductive health. Additionally, the form requests information on operations, hospitalizations other than surgical and childbirth, accidents, family medical history to identify hereditary conditions, habits including substance use, and a detailed list of medications including over-the-counter drugs and supplements. Lastly, it encompasses queries about past tests and immunizations to ensure up-to-date preventive care. This form plays a vital role in enabling healthcare providers to offer tailored and safe medical care by thoroughly understanding the patient’s health history. Copies of the form are accessible on the healthcare provider's website, making it easy for patients to review or prepare in advance.

QuestionAnswer
Form NameNew Patient History Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesSigmoidoscopy, DT, genitourinary new patient questionnaire in pdf, X-RAY

Form Preview Example

NEW PATIENT HISTORY FORM

NAME (LAST, FIRST, MIDDLE)

 

 

 

 

AGE

BIRTHDATE

 

 

 

SEX

 

 

 

 

 

 

 

 

 

 

HOME PHONE

WORK PHONE

OCCUPATION

 

 

 

MARITAL STATUS

 

 

 

 

 

 

 

 

 

S

M

W

D

 

 

 

 

 

 

 

 

EMERGENCY CONTACT

 

 

CONTACT’S PHONE

IF MARRIED, SPOUSE’S NAME

 

 

 

 

 

 

 

 

 

 

 

 

PREVIOUS PHYSICIAN

 

 

 

CURRENT PHYSICIAN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WHICH LOCAL PHARMACY DO YOU USE?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HOW DID YOU HEAR ABOUT OUR PRACTICE?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ALLERGIES TO MEDICATIONS, X-RAY DYES, OR OTHER SUBSTANCES: NO YES

(If yes, please list name of medicine and type of reaction)

__________________________________________________________________________________________

__________________________________________________________________________________________

PAST MEDICAL HISTORY AND REVIEW OF SYSTEMS

(Please check off if you have had any problems with or are presently experiencing any of the following)

High blood pressure Diabetes

Cancer

Chest pain/chest tightness Shortness of Breath Swollen ankles Palpitations Lightheadedness Frequent urination Rheumatic fever

Asthma Emphysema Bronchitis Pneumonia

TB

Persistent cough Abdominal discomfort Indigestion

Nausea

Vomiting

Constipation Diarrhea Blood in stool Ulcers

Change in bowel habits Unexplained weight gain/loss Hemorrhoids

Gall Bladder disease Colitis

Hepatitis or jaundice

Thyroid disease Head or neck radiation Headache

Kidney disease Kidney stones Difficulty urinating Arthritis

Low back problems Gout

Skin diseases

Blood disorders Venereal diseases Anxiety Depression Anemia Alcohol abuse Drug abuse Impotence or Erectile Dysfunction

Other (list below)

__________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________

WOMEN ONLY:

Menstrual Periods

Age onset: _______ Periods regular or irregular: _______________ Still having periods:

Yes

No

Date of last period: _________________ Difficulty with periods: ________________________________

Pregnancies: ______________________ Births: ______________________ Miscarriages: ______________________ Abortions: _________________________

Leakage of Urine:

Pelvic pain:

Abnormal discharge

History of abnormal Pap Smear

No

No

No

No

Yes (Please describe) ____________________________________________________________________________

Yes (Please describe) ____________________________________________________________________________

Yes (Please describe) ____________________________________________________________________________

Yes (Please describe) ____________________________________________________________________________

Copies of all forms are available on our website:

www.wadsworthfamilymedicine.com

Review Date: __________________

Copies of all forms are available on our website:

www.wadsworthfamilymedicine.com

OPERATIONS AND THEIR DATES:

Tonsillectomy _________________

Appendectomy _________________ Hysterectomy _________________

Hernia Repair _________________

Gallbladder ___________________

Other (please list) _______________________________________________________________________________

__________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________

HOSPITALIZATIONS (Other than surgical and childbirth)

__________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________

ACCIDENTS

__________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________

FAMILY HISTORY

 

MOTHER

FATHER

SIBLINGS

Cancer (describe type)

 

_________________

_________________

_________________

Hypertension (high blood pressure)

_________________

_________________

_________________

Heart Disease

 

_________________

_________________

_________________

Diabetes

 

_________________

_________________

_________________

Strokes

 

_________________

_________________

_________________

Mental disease (anxiety, depression etc.)

_________________

_________________

_________________

Drug or alcohol addiction

 

_________________

_________________

_________________

Glaucoma

 

_________________

_________________

_________________

Bleeding diseases

 

_________________

_________________

_________________

Other_____________________________

_________________

_________________

_________________

 

 

 

 

 

 

 

 

 

 

HABITS

 

 

 

 

Smoking

Duration _____________________

Amount _____________________

Quit? When? ___________________

Alcohol

Duration _____________________

Amount _____________________

Quit? When? ___________________

Coffee/Caffeine

Duration _____________________

Amount _____________________

Quit? When? ___________________

Drugs

Duration _____________________

Amount _____________________

Quit? When? ___________________

 

 

 

 

 

MEDICATIONS (Prescriptions, over-the-counter, vitamins, herbs, etc.)

DRUG NAME

DOSE

DRUG NAME

DOSE

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

Copies of all forms are available on our website:

www.wadsworthfamilymedicine.com

TEST AND IMMUNIZATIONS

Yes

Year Performed

Not Sure Never

Comments

Pap Smear (Women)

_____________

 

________________________________________

Breast Mammography

_____________

 

________________________________________

Sigmoidoscopy

_____________

 

________________________________________

Stool Occult Blood

_____________

 

________________________________________

EKG

_____________

 

________________________________________

Tetanus (DT)

_____________

 

________________________________________

Pneumovax

_____________

 

________________________________________

Copies of all forms are available on our website:

www.wadsworthfamilymedicine.com

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Part no. 1 for filling in genitourinary new patient questionnaire in pdf

2. The third stage would be to complete all of the following fields: PAST MEDICAL HISTORY AND REVIEW OF, High blood pressure Diabetes, Asthma Emphysema Bronchitis, Constipation Diarrhea Blood in, Thyroid disease Head or neck, Blood disorders Venereal diseases, Other list below, and WOMEN ONLY Menstrual Periods.

Stage no. 2 of filling out genitourinary new patient questionnaire in pdf

3. In this step, have a look at WOMEN ONLY Menstrual Periods, Age onset Periods regular or, Yes, Date of last period Difficulty, Yes Please describe, Pelvic pain, Abnormal discharge, History of abnormal Pap Smear, Yes Please describe, Yes Please describe, Yes Please describe, Copies of all forms are available, and wwwwadsworthfamilymedicinecom. Each one of these need to be completed with highest awareness of detail.

Stage # 3 of filling in genitourinary new patient questionnaire in pdf

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Filling in part 4 of genitourinary new patient questionnaire in pdf

Be really careful while filling in Review Date and Review Date, because this is where many people make mistakes.

5. To finish your form, the last section includes a few additional blank fields. Entering OPERATIONS AND THEIR DATES, Tonsillectomy Appendectomy, Hernia Repair, Gallbladder, Other please list, HOSPITALIZATIONS Other than, FAMILY HISTORY Cancer describe, MOTHER, FATHER, and SIBLINGS is going to wrap up the process and you'll certainly be done in an instant!

genitourinary new patient questionnaire in pdf conclusion process clarified (stage 5)

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