New Patient Health History New Patient Health History Please help me provide you with a complete evaluation by taking the time (about 15 minutes) to fill out this questionnaire carefully. All answers are confidential. Name*Today's Date* Date Format: MM slash DD slash YYYY Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Place of BirthAgeHeightWeightHome PhoneWork PhoneCell PhoneReferred byEmail* Preferred PronounsOptionalHe/HimShe/HerThey/ThemMarital StatusSingleMarriedDivorcedWidowedLiving withEducationOccupationChildrenNameAge Reason for Visit Today*Other ConcernsHow long have you had this condition?Have you ever experienced this before?What seemed to be the initial cause?What seems to make it better?What seems to make it worse?Does it bother your: Sleep Work Other OtherIf other, what?Family HistoryComplete for each family member, indicating any of the illnesses that they have ever had. Please select the appropriate box(es).Cancer or Tumors Self Mother Father Sibling Spouse Children Diabetes Self Mother Father Sibling Spouse Children Blood or bleeding disorders/anemia Self Mother Father Sibling Spouse Children Seizures Self Mother Father Sibling Spouse Children High blood pressure/heart disease Self Mother Father Sibling Spouse Children Allergies Self Mother Father Sibling Spouse Children Stroke Self Mother Father Sibling Spouse Children Drug abuse Self Mother Father Sibling Spouse Children Depression or mental illness Self Mother Father Sibling Spouse Children Age of DeathMotherFatherSiblingSpouseChildrenHepatitis Self Mother Father Sibling Spouse Children Kidney disorders Self Mother Father Sibling Spouse Children Thyroid disorders Self Mother Father Sibling Spouse Children Muscular-skeletal disorders Self Mother Father Sibling Spouse Children Blood transfusion (if before 1985) Self Mother Father Sibling Spouse Children Parkinson's disease Self Mother Father Sibling Spouse Children AIDS Self Mother Father Sibling Spouse Children Personal Lifestyle Habits(how much, how many, or how often)Cigarettes (packs)Coffee/Tea (cups)Alcohol (drinks per week)MarijuanaOther recreational drugsDietary restrictionsVitamins and herbsFood cravingsDiet: what might you eat in a typical day?BreakfastLunchDinnerSnacksExercise (type of activity)How often?What non-work activities do you enjoy doing?(reading, TV, meditaton, music, etc.)MedicinesList medications you are taking and for what conditionsMedicationCondition List vitamins and herbs you are taking Major HospitalizationsIf you have ever been hospitalized for any serious medical illness or operation, write the most recent ones below (do not include normal pregnancies).HospitalizationsYearOperation/Illness HistoryPlease indicate any current or past health conditionsGENERALInsomniaCurrentPastDreams/nightmaresCurrentPastIrritabilityCurrentPastDepressionCurrentPastMood swingsCurrentPastLethargy/interiaCurrentPastPoor memoryCurrentPastDifficulty making decisionsCurrentPastAnxious or worriedCurrentPastHopeless or negativeCurrentPastCry easilyCurrentPastFearfull/fearlessCurrentPastLose temper easilyCurrentPastDifficult to express sympathyCurrentPastDifficult to express joyCurrentPastEasily startledCurrentPastExtremely organizedCurrentPastSpiritualCurrentPastEver considered suicideCurrentPastRecent weight loss/gainCurrentPastCold hands or feetCurrentPastTends to push when exhaustedCurrentPastInflexibleCurrentPastLyme diseaseCurrentPastBroken bonesCurrentPastNails split/crackCurrentPastSwelling of hands/feetCurrentPastTumors/growthsCurrentPastNight sweatingCurrentPastExcess sweatingCurrentPastDifficulty being still/relaxingCurrentPastWater retention/bloatingCurrentPastEasily overheats or overchillsCurrentPastNeeds to sleep a lotCurrentPastOther or explanation:HEAD AND NECKHeadachesCurrentPastMigrainesCurrentPastStiff neckCurrentPastDizzinessCurrentPastFaintingCurrentPastSwollen glandsCurrentPastHair loss/thinningCurrentPastOther or explanation:EARSRingingCurrentPastHearing loss/hearing aidsCurrentPastInfections/earacheCurrentPastVertigoCurrentPastMotion, air or seasicknessCurrentPastOther or explanation:EYESGlasses/contact lensesCurrentPastBlurred vision/double visionCurrentPastPoor night visionCurrentPastSpots or floatersCurrentPastEye inflammationCurrentPastGlaucoma/cataractsCurrentPastPain or itchingCurrentPastWatery or too dryCurrentPastRecent laser surgeryCurrentPastOther or explanation:NOSE, THROAT AND MOUTHSinus infectionCurrentPastHay fever/allergiesCurrentPastFrequent sore throatCurrentPastDifficulty swallowingCurrentPastMouth and tongue ulcersCurrentPastFrequent coldsCurrentPastNosebleed/dry noseCurrentPastNasal congestionCurrentPastLoss of voiceCurrentPastThirstCurrentPastExcessive phlegmCurrentPastTMJCurrentPastFacial painCurrentPastGum problemsCurrentPastDry mouthCurrentPastLoss of taste or smellCurrentPastOther or explanation:SKINHives/rashesCurrentPastEczema/PsoriasisCurrentPastDry skinCurrentPastEasy bruisingCurrentPastChanges in moles/lumpsCurrentPastItchingCurrentPastDandruffCurrentPastRecent dermabrasionCurrentPastRecent BotoxCurrentPastOther or explanation:RESIPIRATORYDifficulty breathingCurrentPastWheezingCurrentPastAsthmaCurrentPastChronic coughCurrentPastWet coughCurrentPastDry coughCurrentPastCoughing up phlegmCurrentPastCoughing up bloodCurrentPastShortness of breathCurrentPastTight chestCurrentPastPneumoniaCurrentPastOther or explanation:CARDIOVASCULARHigh/low blood pressureCurrentPastChest pain or tightnessCurrentPastPalpitationCurrentPastRapid heart beatCurrentPastIrregular heart beatCurrentPastPoor circulationCurrentPastSwollen ankles/phlebitisCurrentPastAnemiaCurrentPastHistory of heart attackCurrentPastVaricose veinsCurrentPastOther or explanation:GASTROINTESTINALNausea/vomitingCurrentPastIndigestion/slow digestionCurrentPastStomach painCurrentPastDiarrheaCurrentPastConstipationCurrentPastPoor appetiteCurrentPastExcessive/deficient hungerCurrentPastFlatulenceCurrentPastBurping/hiccupsCurrentPastAcid regurgitationCurrentPastBloatingCurrentPastLaxative useCurrentPastBloody stoolCurrentPastMucus in stoolCurrentPastHemorrhoidsCurrentPastLiver/gall bladder disorderCurrentPastColitis/diverticulitisCurrentPastCronesCurrentPastUlcerCurrentPastOther or explanation:MUSCULOSKELETAL JOINT PAIN/DISORDERSore musclesCurrentPastWeak musclesCurrentPastDifficulty walkingCurrentPastNeck/shoulder painCurrentPastBack painCurrentPastRib painCurrentPastLimited range of motionCurrentPastOther or explanation:NEUROLOGICALSeizuresCurrentPastTremorsCurrentPastNumbness or tinglingCurrentPastPainCurrentPastParalysisCurrentPastPoor coordinationCurrentPastEpliepsy or convulsionsCurrentPastFaining spellsCurrentPastOther or explanationGENITAL-URINARYPain on urinationCurrentPastFrequent urinationCurrentPastUrgent urinationCurrentPastBlood in urineCurrentPastUnable to hold urineCurrentPastIncomplete urinationCurrentPastBedwettingCurrentPastWake to urinateCurrentPastIncreased libidoCurrentPastDecreased libidoCurrentPastKidney stonesCurrentPastImpotenceCurrentPastPremature ejaculationCurrentPastNocturnal emissionCurrentPastPain/itching of genitaliaCurrentPastLumps in testiclesCurrentPastOther or explanationINFECTION SCREENINGParasitesCurrentPastHIV risks: self or partnerCurrentPastTB: self or householdCurrentPastHepatitis risk: self or partnerCurrentPastSTDs: self or partnerCurrentPastGenital wartsCurrentPastHerpes: oral/genitalCurrentPastOther infection (describe)EmailThis field is for validation purposes and should be left unchanged.
