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Medical History - Patient Questionnaire
As a new patient, you have a lot of background to share with us. Use this template when you are visiting for the first time. Fill this out
to bring with you to the appointment to simplify the registration process. Keep a copy for your records so that it is available when you
need to visit other doctors.

Important tip: The information you entered is not saved to protect your privacy. Please print this page after entering the data so you
                          don't lose your information.
First name:
Second name:   
Address:   ZIP:     
Phone:   Freetext:     
Fax:      
 
 1. Is there anyone in your family with heart disease, high blood pressure, diabetes, kidney,
     cancer or other medical problems?		 Yes No
 
 Please list any conditions and select how the person is related to you:
 Condition: Relationship:
Condition:     Relationship:    
Condition:     Relationship:    
Condition:     Relationship:    
Condition:     Relationship:    
 
 2. List your current physicians:
Specialty:
    Specialty:  
    Specialty:  
 3. Enter the date of your last physical exam and list the physician who saw you:
Month / Year  Physician:  
 
 4. (Women only) Enter the date of your last OB/GYN exam and list the physician who saw you:
Month / Year   Physician:  
 
 5. List any medical conditions you have and for how long you've had the condition ( first month / year
     diagnosed)
 Condition  
 Month / Year    
Condition     Month / Year        
Condition     Month / Year        
Condition     Month / Year        
Condition     Month / Year        
 
 6. Have you ever gone to an emergency room for treatment in the last year?
 Yes No
     How many times in the past year?  
    List the reason and when you made each ER visit.
Reason  
 Month / Year   
Reason     Month / Year     
Reason     Month / Year     
 
 7. Have you ever stayed in the hospital overnight during the past year?
 Yes No
     How many times in the past year?  
    List the reason and when you stayed overnight
Reason  
 Month / Year   
Reason     Month / Year       
Reason     Month / Year       
 
 8. Have you had surgery?
     List the type of surgery or reason for surgery including dates.
 Yes No
Reason  
 Month / Year   
Reason     Month / Year       
Reason     Month / Year       
 
 9. List any allergies you have to food or medications. ( Tip: Only 5 lines available, so summarize ).
 
 10. Have you ever had an anaphylactic reaction (turning red, overall swelling,
       difficulty breathing?		 Yes No
 
 11. Do you smoke? Yes No
      Select which products you use, how much, and number of years used.
      Tobacco product: 
 How much: Years
 
 12. Do you drink alcohol?
 Yes No
               Beer 
 Wine Liquor
 
 13. Do you take any recreational drugs? Yes No
 
 14.  Are you taking any prescription drugs currently?
 Yes No
        List drugs, dosage, and how often you take them
         Drug Name: Dosage How often:
Drug Name:   Dosage     How often:  
Drug Name:   Dosage     How often:  
 
 15. Summarize. To avoid errors, bring in any medications your child takes in their original bottles.
  Important tip: The information you entered is not saved to protect your privacy. Please print this page now so you
                          don't lose your information.