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Date:________________________________ Patient Name( First Last ):________________________ Referred by:_________________________ Mailing Address:_____________________ Telephone:___________________________ Your Email Address:__________________ Date of Birth:_______________________ Gender: Male Female Primary Care Physician Name, Address and Phone:__________________ Referring Physician, if different from above:_______________________ Emergency Contact Name:______________ Relationship:________________________ Phone:_______________________________ Your Height:_________________________ Your Weight:_________________________ What seems to be the problem? What is the reason for consultation? These are basic questions. There are many more. |
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Are you a new patient? Age: Date of last Physical Examination: What is your reason for visit? Symptoms General Symptoms Chills Depression Dizziness Fainting Fever Forgetfulness Headache Loss of Sleep Loss of Weight Nervousness Numbness Sweats Muscle / Joint / Bone Symptoms Pain weakness or numbness in : Arms Hips Back Legs Feet Neck Hands Shoulders Genito-Urinary Symptoms Blood in Urine Frequent Urination Lack of Bladder Control Painful Urination Gastrointestinal Appetite Poor Bloating Bowel Changes Constipation Diarrhea Excessive Hunger Excessive Thirst Gas Hemorrhoids Indigestion Nausea Rectal Bleeding Stomach Pain Vomiting Vomiting Blood Cardiovascular Chest Pain High Blood Pressure Irregular Heart Beat Low Blood Pressure Poor Circulation Rapid Heart Beat Swelling of Ankles Varicose Veins Eye, Ear, Nose, Throat Bleeding Gums Blurred Vision Crossed Eyes Difficulty Swallowing Double Vision Earache Ear Discharge Hay Fever Hoarseness Loss of Hearing Nosebleeds Persistent Cough Ringing In Ears Sinus Problems Vision - Flashes Vision-Halos Skin Bruise Easily Hives Itching Change in Moles Rash Scars Sore That Wont Heal MEN Only Breast Lump Erection Difficulties Lump in Testicles Penis Discharge Sore on Penis Other WOMEN Only Abnormal Pap Smear Bleeding Between Periods Breast Lumps Extreme Menstrual Pain Hot Flashes Nipple Discharge Painful Intercourse Vaginal Discharge Other Date of Last Menstrual Period: Date of Last Pap Smear: Have You Had A Mammogram? Are You Pregnant? Number Of Children: Conditions Chemical Dependency High Cholesterol Psychiatric Care Alcoholism Chicken Pox Kidney Disease Rheumatic Fever Anemia Diabetes Liver Disease Scarlet Fever Anorexia Emphysema Measles Stroke Appendicitis Epilepsy Migraine Headaches Suicide Attempt Arthritis Glaucoma Miscarriage Syphilis Asthma Goiter Mononucleosis Thyroid Problems Bleeding Disorders Gonorrhea Multiple Sclerosis Tonsilitis Breast Lump Gout Mumps Tuberculosis Bronchitis Heart Disease Pacemaker Typhoid Fever Bulimia Hepatitis Pneumonia Ulcers Cancer Hernia Polio Vaginal Infections Cataracts Herpes Prostate Problem Venereal Disease Medications: List medications you are currently taking: Pharmacy: Pharmacy Phone: Allergies : Are you allergic to any medications? If yes, please list all medications to which you are allergic : Please list any other known allergies: Family History : Relation Age State of Health Age at Death Cause of Death Father Mother Brother 1 Brother 2 Brother 3 Brother 4 Sister 1 Sister 2 Sister 3 Sister 4 Check if your blood relatives had any of the following : Disease : Relationship to You : Arthritis, Gout Asthma, Hay Fever Cancer Chemical Dependency Diabetes Heart Disease, Strokes High Blood Pressure Kidney Disease Tuberculosis Other Hospitalizations : Please list all hospitalizations including YEAR, HOSPITAL, and REASON for Hospitalization, and OUTCOME : Have you ever had a Blood Transfusion ? If YES, please give approximate dates: Serious Illness/Injuries : Please list all Serious Injuries including TYPE OF INJURY, YEAR, and OUTCOME : Pregnancies : Please list all Pregnancies including YEAR OF BIRTH, SEX, and COMPLICATIONS if any : Health Habits : Substance Used : How Much / Frequency : Caffeine Tobacco Drugs Other Occupational : Check if your work exposes you to the following : Stress Hazardous Substances Heavy Lifting Other Your Occupation : Residence : List states or foreign regions of prior residence with dates: List domestic and/or international travel with dates: I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any members of his/her staff responsible for any errors or omissions that I may have made in the completion of this form What should be your first question in case a patient is referred to you? |