New Patient – History

Your Identity
First Name
Last Name
MIddle Name
Account Number
Due to the new healthcare laws, the following information is REQUIRED. Please fill out in FULL
Are you a twin?
If you are a twin, are you identical twins?
Identical Twins?
If you are a twin, are you fraternal twins?
Fraternal Twins?
What was your birth order in relation to your siblings? For example, if you were born first, please enter the number 1.
Birth Order
How many full brothers do you have?
How many half brothers do you have?
How many full sisters do you have?
How many half sisters do you have?
How many sons do you have?
How many daughters do you have?
Are you adopted?
FAMILY HISTORY Checkmark if an IMMEDIATE family member had any of the following:
Family History of
MEDICAL HISTORY. Please check if you have EVER had any of the following:
Medical History
Any additional Medical History you would like us to know about:
Due to the new healthcare laws, the following information is REQUIRED. Please fill out in FULL
Additional Medical History:
Vaccinations What year were you last vaccinated for the following:
Tetanus
Flu
Pneumonia
Hepatitis
Tuberculosis
If applicable, when was the date of your last exam for the following
Eye
Dental
Rectal
Stool
Females
Menstrual Flow
Pain / Cramps
Days of Flow
First day of your last period
Number of the following you have experienced:
Pregnancies
Abortions
Miscarriages
Live Births
If applicable, please note your current birth control method:
Bith Control Method:
Do you currently experience menopausal symptoms such as hot flashes / flushing?