Patient HistoryDate______

Name______Age______Date of Birth______Phone ______

Recent Primary Care Physician______Are you Changing Primary Care to This facility: Y/N

Current Medication:If you are a returning patient with no change to medication check here------

NameStrength (i.e. 25mg) Amount (i.e. 1 tab…) Frequency (Once in AM, twice a day…) 30/90 day supply

Past Medical History:If you are a returning patient with no change to History check here------

Check all that apply to you, list additional in remaining boxes

Asthma / Blood Transfusion / Heart Murmur / Glaucoma / Sleep Apnea / Heart Disease
Angina / Cancer______/ Heart Attack / GERD / Blood Clot / Thyroid
Arthritis / Chronic Pain / High Blood Press / Kidney Stone / Colitis / Diabetes
Aneurysm / Cirrhosis / High Cholesterol / Pancreatitis / HIV/AIDS
Anemia / Emphysema/COPD / Hepatitis _____ / Stroke / Ulcers
A. Fib / Diverticulosis/itis / Hearing Loss / Tuberculosis / Allergies

Immunizations:If you are a returning patient with no change to Immunizations check here------

Year Year Year Year Other

Flu / ZostaVax (shingles) / Hepatitis A
Pneumovax (Pneumonia) / Tetanus / TdaP / Hepatitis B

Medication Allergies: If you are a returning patient with no change to allergies check here------

Medication Reaction Medication Reaction MedicationReaction

Surgical History:If you are a returning patient with no change to surgical history check here------

Surgery Year Surgery YearSurgery Year

Colonoscopy

Hospitalization: If you are a returning patient with no hospitalizations since last visit check here------

Date / Reason / Date / Reason

Family History: If you are a returning patient with no change to family history check here------

Arthritis / Blood Press / Colon Cancer / Stroke
Blood Clots / Cholesterol / Breast Cancer / Melanoma
Diabetes / Heart disease / Prostate cancer / Thyroid

Social History:If you are a returning patient with no change to social history check here------

Marital Status / Tobacco Use / None/Current/Former
Employment Status / Alcohol Use / None/Current/Former
Number of Children / Recreational Drug Use / None/Current/Former

Gynecological History: If you are a returning patient with no change to gyn history check here------

Date Date Date

Last PAP / Last Mammogram / Last Bone Density Scan

Patient/Guardian Signature ______By signing I acknowledge that above information is correct to the best of my knowledge.

Name______Date of Birth______

To help your appointment flow in a timely fashion and avoid overlooking issues, please list the 4 issues you wish to address in your time with the doctor today: (i.e. follow up on blood pressure, sore throat…)

1.______2.______

3.______4.______

Please Circle all that apply to the above listed complaints and to today’s visit:

ConstitutionalChillsFatigueFeverWeight loss/Gain

EyesBlurring of visionChange in vision Eye Drainage

Ears, Nose, Mouth & ThroatEar painHearing lossNasal congestion Nose bleeds Runny Nose Sore throat

Respiratory Cough Shortness of breathSputum Production Wheezing

CardiovascularLeg swelling Chest painCold extremities Palpitations

GastrointestinalBlack stoolsBlood in stoolChange in bowel habits Constipation Diarrhea Heartburn Nausea Vomiting

Female ReproductiveVaginal dischargeVaginal itching Breast lumps Nipple discharge Hot flashes Irregular menses

Male ReproductiveDifficulty with erectionTesticular pain or swelling

GenitourinaryPainful urinationFrequent UrinationBlood in urine Urinary retention Urinary urgency
Musculoskeletal Muscle pain Joint painJoint SwellingBack pain

Integumentary (Skin)RashItching Suspicious Mole

NeurologicalNumbnessSlurred speechBurning pain in feetConfusion Dizziness Headache Memory loss Tremor Weakness

Psychiatric AnxietyDepressionInsomniaSuicidal Thoughts

Endocrine Cold intoleranceExcessive thirstExcessive urinationHair changes Heat intolerance