New Patient – History Your IdentityFirst NameLast NameMIddle NameAccount NumberDue to the new healthcare laws, the following information is REQUIRED. Please fill out in FULLAre you a twin?YesNoIf you are a twin, are you identical twins?Identical Twins?YesNoIf you are a twin, are you fraternal twins?Fraternal Twins?YesNoWhat was your birth order in relation to your siblings? For example, if you were born first, please enter the number 1.Birth OrderHow 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 ofAlcoholismCancerHay FeverHeart DiseaseAnemiaDiabetesHepatitisMigraineArthritisEpilepsyHypertensionThryoid DiseaseAsthmaGlaucomaLipid DisorderBleeding EasilyMental IllnessMEDICAL HISTORY. Please check if you have EVER had any of the following:Medical HistoryAbdominal Pain-ChronicDiarrheaHoarseness - ProlongedSexual ProblemsAIDS/HIVDiverticulosisIrregular PulseShinglesAllergies (Seasonal)Dizzy SpellsJaundiceShortness of BreathAsthmaEczemaMeaslesSinus TroubleBack PainGallbladder DiseaseMental IllnessSleep ProblemsBloody or tarry stoolsGerman MeaaslesMumpsSore Throat - FrequentBronchitisGoutNauseaSTDCancerHay FeverNose Bleeds - FrequientStrokesChest PainHeadachesOsteoporosisSwollen AnklesChicken PoxHearing ProblemsPeptic UlcerThroid DiseaseChronic CoughHeartburnPleurisyTuberculosisConcentration ProblemsHeart MurmurPneumoniaUrinary ProblemsConstipationHemorrhoidsPolioVision ProblemsCOPDHepatitisPsoriasisVomitingCrohn’s DiseaseHerniaRashesWeight Gain__Decreased AppetitieHerpesRheumatic FeverWeight Loss__DepressionHigh Blood PressureRheumatismWheezing__DiabetesHivesSeizuresAny 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 FULLAdditional Medical History:Vaccinations What year were you last vaccinated for the following:TetanusFluPneumoniaHepatitisTuberculosisIf applicable, when was the date of your last exam for the followingEyeDentalRectalStoolFemalesMenstrual FlowRegularIrregularPain / CrampsYesNoDays of FlowFirst day of your last periodNumber of the following you have experienced:PregnanciesAbortionsMiscarriagesLive BirthsIf applicable, please note your current birth control method:Bith Control Method:Do you currently experience menopausal symptoms such as hot flashes / flushing?YesNoSend Print Form
