New Patient Medical History

New patients can save time before their first visit by completing the patient history form, along with our other forms. You can fill this form in online, print it and bring it with you to your first appointment.

If you need to provide the form to someone else or complete it away from the computer, you can print the blank form and fill it out later (download PDF).

1 Start 2 Preview and Print 3 Complete

Date *

Month

Day

Year

Patient First Name *

Patient Last Name *

Address *

Birth Date *

Month

Day

Year

Have you ever been in the hospital or had surgery? If yes for what and when? *

Pregnancies

Total Number of Pregnancies

blank or 0 if none, or 1, 2 ,3, etc.

Number of Children

Number of Miscarriages

Number of Abortions

Medical History

Anemia

Arthritis

Asthma

Cancer

Diabetes

Fibroids

Glaucoma

Gout

Hearing Loss

Visual Loss

Chest Pain

Heart Attack

Heart Disease

High Blood Pressure

Any Other Bleeding

Gastrointestinal Bleeding

Easy Bruising

HIV

Kidney Disease

Liver Disease

Lung Disease

Shortness of Breath

Prostate Disease

Psychiatric Problems

Alcoholism

Drug/Substance Abuse

Seizures

Stroke

Sexually Transmitted Disease

Abnormal Penile Discharge

Abnormal Vaginal Discharge

Thyroid Disease

Tuberculosis

Ulcers

Urinary Incontinence

Difficulty Urinating

Please check all past or present medical problems and/or symptoms

Medication History: Please list medications you are currently taking

Medication 1

How Often? (1)

For what problem? (1)

Medication 2

How Often? (2)

For what problem? (2)

Medication 3

How Often? (3)

For what problem? (3)

Medication 4

How Often? (4)

For what problem? (4)

Medication 5

How Often? (5)

For what problem? (5)

Medication 6

How Often? (6)

For what problem? (6)

Allergies

Family History

Father's Age

Father's Medical Problems or Cause of Death

Mother's Age

Mother's Medical Problems or Cause of Death

Other relationship

Other's Age

Other's Medical Problems or Cause of Death

Health Screenings/Immunizations

Pap Smear Date and Results

Stress Test Date and Results

Mammogram Date and Results

Bone Density Date and Results

Chest X-ray Date and Results

Physical Examination Date and Results

Digital Rectal Exam Date and Results

Prostate Examination/PSA Date and Results

Stool Hemoccults Date and Results

Flexible Sigmoidoscopy Date and Results

Colonoscopy Date and Results

Cholesterol Date and Results

Blood Sugar Date and Results

Tuberculosis/PPD Test Date and Results

Influenza Vaccine Date

Tetanus/TD Date

Hepatitis B Vaccine Date

Pneumococcal Vaccine Date

Shingles Vaccine Date

B.M.I. Date and Results

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New Patient Medical History