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*
MM slash DD slash YYYY
Address*
Street Address City State ZIP Code
Date of Birth*
Place of Birth
Age
Height
Weight
Home Phone
Work Phone
Cell Phone
Referred by
Email*
Preferred Pronouns
Marital Status
- Single
- Married
- Divorced
- Widowed
Living with
Education
Occupation
Children
Name Age
Reason for Visit Today*
Other Concerns
How 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
Other
If other, what?
Family History
Complete 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 Death
Mother Father Sibling Spouse Children
Hepatitis
- 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)
Marijuana
Other recreational drugs
Dietary restrictions
Vitamins and herbs
Food cravings
Diet: what might you eat in a typical day?
Breakfast
Lunch
Dinner
Snacks
Exercise (type of activity)
How often?
What non-work activities do you enjoy doing?
(reading, TV, meditaton, music, etc.)
Medicines
List medications you are taking and for what conditions
Medication Condition
List vitamins and herbs you are taking
Major Hospitalizations
If you have ever been hospitalized for any serious medical illness or operation, write the most recent ones below (do not include normal pregnancies).
Hospitalizations
Year Operation/Illness
History
Please indicate any current or past health conditions
GENERAL
Insomnia
- Current
- Past
Dreams/nightmares
- Current
- Past
Irritability
- Current
- Past
Depression
- Current
- Past
Mood swings
- Current
- Past
Lethargy/interia
- Current
- Past
Poor memory
- Current
- Past
Difficulty making decisions
- Current
- Past
Anxious or worried
- Current
- Past
Hopeless or negative
- Current
- Past
Cry easily
- Current
- Past
Fearfull/fearless
- Current
- Past
Lose temper easily
- Current
- Past
Difficult to express sympathy
- Current
- Past
Difficult to express joy
- Current
- Past
Easily startled
- Current
- Past
Extremely organized
- Current
- Past
Spiritual
- Current
- Past
Ever considered suicide
- Current
- Past
Recent weight loss/gain
- Current
- Past
Cold hands or feet
- Current
- Past
Tends to push when exhausted
- Current
- Past
Inflexible
- Current
- Past
Lyme disease
- Current
- Past
Broken bones
- Current
- Past
Nails split/crack
- Current
- Past
Swelling of hands/feet
- Current
- Past
Tumors/growths
- Current
- Past
Night sweating
- Current
- Past
Excess sweating
- Current
- Past
Difficulty being still/relaxing
- Current
- Past
Water retention/bloating
- Current
- Past
Easily overheats or overchills
- Current
- Past
Needs to sleep a lot
- Current
- Past
Other or explanation:
HEAD AND NECK
Headaches
- Current
- Past
Migraines
- Current
- Past
Stiff neck
- Current
- Past
Dizziness
- Current
- Past
Fainting
- Current
- Past
Swollen glands
- Current
- Past
Hair loss/thinning
- Current
- Past
Other or explanation:
EARS
Ringing
- Current
- Past
Hearing loss/hearing aids
- Current
- Past
Infections/earache
- Current
- Past
Vertigo
- Current
- Past
Motion, air or seasickness
- Current
- Past
Other or explanation:
EYES
Glasses/contact lenses
- Current
- Past
Blurred vision/double vision
- Current
- Past
Poor night vision
- Current
- Past
Spots or floaters
- Current
- Past
Eye inflammation
- Current
- Past
Glaucoma/cataracts
- Current
- Past
Pain or itching
- Current
- Past
Watery or too dry
- Current
- Past
Recent laser surgery
- Current
- Past
Other or explanation:
NOSE, THROAT AND MOUTH
Sinus infection
- Current
- Past
Hay fever/allergies
- Current
- Past
Frequent sore throat
- Current
- Past
Difficulty swallowing
- Current
- Past
Mouth and tongue ulcers
- Current
- Past
Frequent colds
- Current
- Past
Nosebleed/dry nose
- Current
- Past
Nasal congestion
- Current
- Past
Loss of voice
- Current
- Past
Thirst
- Current
- Past
Excessive phlegm
- Current
- Past
TMJ
- Current
- Past
Facial pain
- Current
- Past
Gum problems
- Current
- Past
Dry mouth
- Current
- Past
Loss of taste or smell
- Current
- Past
Other or explanation:
SKIN
Hives/rashes
- Current
- Past
Eczema/Psoriasis
- Current
- Past
Dry skin
- Current
- Past
Easy bruising
- Current
- Past
Changes in moles/lumps
- Current
- Past
Itching
- Current
- Past
Dandruff
- Current
- Past
Recent dermabrasion
- Current
- Past
Recent Botox
- Current
- Past
Other or explanation:
RESIPIRATORY
Difficulty breathing
- Current
- Past
Wheezing
- Current
- Past
Asthma
- Current
- Past
Chronic cough
- Current
- Past
Wet cough
- Current
- Past
Dry cough
- Current
- Past
Coughing up phlegm
- Current
- Past
Coughing up blood
- Current
- Past
Shortness of breath
- Current
- Past
Tight chest
- Current
- Past
Pneumonia
- Current
- Past
Other or explanation:
CARDIOVASCULAR
High/low blood pressure
- Current
- Past
Chest pain or tightness
- Current
- Past
Palpitation
- Current
- Past
Rapid heart beat
- Current
- Past
Irregular heart beat
- Current
- Past
Poor circulation
- Current
- Past
Swollen ankles/phlebitis
- Current
- Past
Anemia
- Current
- Past
History of heart attack
- Current
- Past
Varicose veins
- Current
- Past
Other or explanation:
GASTROINTESTINAL
Nausea/vomiting
- Current
- Past
Indigestion/slow digestion
- Current
- Past
Stomach pain
- Current
- Past
Diarrhea
- Current
- Past
Constipation
- Current
- Past
Poor appetite
- Current
- Past
Excessive/deficient hunger
- Current
- Past
Flatulence
- Current
- Past
Burping/hiccups
- Current
- Past
Acid regurgitation
- Current
- Past
Bloating
- Current
- Past
Laxative use
- Current
- Past
Bloody stool
- Current
- Past
Mucus in stool
- Current
- Past
Hemorrhoids
- Current
- Past
Liver/gall bladder disorder
- Current
- Past
Colitis/diverticulitis
- Current
- Past
Crones
- Current
- Past
Ulcer
- Current
- Past
Other or explanation:
MUSCULOSKELETAL JOINT PAIN/DISORDER
Sore muscles
- Current
- Past
Weak muscles
- Current
- Past
Difficulty walking
- Current
- Past
Neck/shoulder pain
- Current
- Past
Back pain
- Current
- Past
Rib pain
- Current
- Past
Limited range of motion
- Current
- Past
Other or explanation:
NEUROLOGICAL
Seizures
- Current
- Past
Tremors
- Current
- Past
Numbness or tingling
- Current
- Past
Pain
- Current
- Past
Paralysis
- Current
- Past
Poor coordination
- Current
- Past
Epliepsy or convulsions
- Current
- Past
Faining spells
- Current
- Past
Other or explanation
GENITAL-URINARY
Pain on urination
- Current
- Past
Frequent urination
- Current
- Past
Urgent urination
- Current
- Past
Blood in urine
- Current
- Past
Unable to hold urine
- Current
- Past
Incomplete urination
- Current
- Past
Bedwetting
- Current
- Past
Wake to urinate
- Current
- Past
Increased libido
- Current
- Past
Decreased libido
- Current
- Past
Kidney stones
- Current
- Past
Impotence
- Current
- Past
Premature ejaculation
- Current
- Past
Nocturnal emission
- Current
- Past
Pain/itching of genitalia
- Current
- Past
Lumps in testicles
- Current
- Past
Other or explanation
INFECTION SCREENING
Parasites
- Current
- Past
HIV risks: self or partner
- Current
- Past
TB: self or household
- Current
- Past
Hepatitis risk: self or partner
- Current
- Past
STDs: self or partner
- Current
- Past
Genital warts
- Current
- Past
Herpes: oral/genital
- Current
- Past
Other infection (describe)
Comments
This field is for validation purposes and should be left unchanged.

Name	Age

Medication	Condition

Year	Operation/Illness

New Patient Health History

Family History

Personal Lifestyle Habits

Medicines

Major Hospitalizations

History

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