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New Patient Form

The FREE colorful table format New Patient Questionnaire is a comprehensive medical history form designed to be filled out by the health care consumer prior to a visit with a health care provider. This MedicalTemplate is appropriate for a new patient evaluation or any visit to a health care provider.

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100% found this document useful (4 votes)

3K views7 pages

New Patient Form

Uploaded by

e-MedTools

We take content rights seriously. If you suspect this is your content, claim it here.

Available Formats

Download as PDF or read online on Scribd

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Health Care Consumer Questionnaire Patient DOB Date

Patient Name Date

DOB Gender Female Male SSN
Patient Address Phone Emergency Contact Phone
H H
W W
C C
Primary Insurance Phone Secondary Insurance Phone

Policy # Policy #
List ALL Health Care Providers from whom you are currently receiving care (or have seen within the past 12 months),
AND ALL Health Care Providers from whom you are obtaining prescriptions.
Health Care Provider Phone Health Care Provider Phone

Have you completed Advance Health Care Directives? Yes No Please provide a copy as soon as possible
(Living Will or Durable Power of Attorney for Healthcare)
If yes, please provide the name and contact information for your Health Care Power of Attorney

If No, whom would you prefer as a surrogate decision maker should you need one?

Do you have any religious or cultural beliefs that may affect your healthcare? If yes, explain

Describe the means by which you prefer to learn new information

Verbal Instruction Written Instruction Handouts Visual (Pictures, Videos, etc)
Language you prefer to converse in
Level of education completed
<6th grade 6th – 8th grade 9th grade 12th grade 1-4 years college >4 years college
If the person completing this form is not the patient, please write your full name, relationship to the
patient, and the specific reasons that the patient is unable to complete this form.

MB & RR 2008 e-medtools.com The information on this page was reviewed with the patient HCC Initials _____ HCP Initials _____ 1
Health Care Consumer Questionnaire Patient DOB Date
Allergies Please describe reactions
Shellfish
IV Contrast
Penicillins
Other, specify
Please list medications you are taking. Include ALL over the counter medications, herbs & vitamins.
Medication & Dose Frequency Medication & Dose Frequency

Have you ever been exposed to known cancer-causing agents or inhalation hazards? Yes No
If yes, please list the agents as specifically as possible, and state the duration of exposure as best as possible.
Agent Duration Agent Duration

Please list and describe your hobbies

Have you traveled in the past 12 months? Yes No If yes, please list locations and time spent traveling.
Within the United States Duration Outside the United States Duration

Do you exercise? Yes No If yes, please describe activities, frequency and duration of each activity
Activity & Duration Times/Week Activity & Duration Times/Week

MB & RR 2008 e-medtools.com The information on this page was reviewed with the patient HCC Initials _____ HCP Initials _____ 2
Health Care Consumer Questionnaire Patient DOB Date
Substance Use and Personal Risk History
Have you ever smoked tobacco as cigarettes, cigars or pipes? Yes No #Packs #Years
Have you quit? If yes, when Yes No
Have you ever chewed tobacco? Yes No #Pouches #Years
Have you quit? If yes, when Yes No
Have you considered quitting? Yes No
Have you tried quitting? If yes, for how long did you quit? Yes No

Do you drink alcohol? Yes No #Drinks Day Week

1 “drink” is equal to 12 oz. beer,1.5 oz. 80-proof liquor, or 5 oz. glass of wine
Have you ever lost consciousness as a result of drinking alcohol? Yes No
Have you ever had a “drink” to prevent tremors, sweats, or irritability? Yes No
Have you ever been ticketed or arrested for a DUI? Yes No
Have you been involved in a motor vehicle accident in the past 12 months? Yes No

Have you ever used drugs for recreational purposes? Yes No Check all that apply
Amphetamines Cocaine Heroin Inhalants LSD Marijuana PCP Other, specify
Method of drug delivery you used Ingestion Injection Inhalation
How much of each drug would you use? List drugs below Amount Frequency
Day Week
Day Week
Day Week
Check all that apply
Have you ever been dependent on prescription drugs? Yes No Narcotics
Benzodiazepines
Specify If Other
Are you sexually active? Yes No
If yes, do you use contraception of any kind? Check all that apply
Condoms Diaphragm Intrauterine Device IUD Pills, Implants, Patches
How many sexual partners have you had in the past 12 months? #
Do you feel safe in your relationship? Yes No
Have you ever been in a relationship where you were threatened, hurt or afraid? Yes No
Do you have a safe place to go, and do you have the resources to leave, if you feel threatened? Yes No
Have you ever had sex with a person who is the same gender as yourself, bisexual, Yes No
or anyone who performs sexual favors in exchange for money or drugs?
Have you ever been diagnosed with a sexually transmitted disease (such as syphilis, Yes No
HIV, herpes, gonorrhea, chlamydia or genital warts)?

Do you have any tattoos or body piercings? Yes No
Have you ever received transfusions of blood or blood products? Yes No

Describe your seatbelt use whether you are driving or are a passenger in a vehicle.
All the time Most of the time About half the time Rarely Never

Do you keep firearms in your residence? Yes No

If yes, are they kept in locked compartments, or do they have safety locks on when not in use? Yes No

Can you perform your own hygiene, dressing, cooking and shopping needs? Yes No

MB & RR 2008 e-medtools.com The information on this page was reviewed with the patient HCC Initials _____ HCP Initials _____ 3
Health Care Consumer Questionnaire Patient DOB Date
Prior Diagnostic Exam History Have you ever had the following exams? If so, list where and when.
Exam Location and Month/Year
PAP Smear Yes No
Prostate Biopsy Yes No
Mammogram Yes No
Colonoscopy Yes No
EGD (Esophageal endoscopy) Yes No
EKG Yes No
Cardiac Stress Test Yes No
ECHO (Echocardiogram) Yes No
Chest X-ray Yes No
CT “Cat” Scan of Chest Yes No
Pulmonary Function Test Yes No
EEG (Electroencephalography) Yes No
Bone Density Test Yes No
Vaccinations Have you had any of the following vaccines? Check all that apply, and state date last received.
Vaccine Date Received
Influenza Yes No
Pneumonia Yes No
Tetanus Yes No
BCG Yes No
Varicella Yes No
Human Papilloma Virus (Gardasil) Yes No
Gynecologic History This section to be completed by females. Males should skip to next section.
Have you ever been pregnant? Yes No #Live births #Miscarriages or Abortions
How old were you when you started menstruating?
How old were you when you started menopause?
Have you ever used birth control pills, patches or implants? Yes No If yes, when
Have you ever taken hormone replacement therapy? Yes No If yes, when
Have you ever had an intrauterine (IUD) device? Yes No If yes, when
If you had an IUD placed, was it removed? Yes No If yes, when
Have you had a tubal ligation? Yes No If yes, when
Have you had your ovaries surgically removed? Yes No If yes, when
Surgical History Please list all surgical procedures you have had. Include physician’s name, and date of procedure.
Surgical Procedure Physician Date

MB & RR 2008 e-medtools.com The information on this page was reviewed with the patient HCC Initials _____ HCP Initials _____ 4
Health Care Consumer Questionnaire Patient DOB Date
Past Medical History Check “yes” or “no” for each problem listed.
Adrenal Dysfunction Yes No Irregular Heart Rhythm Yes No
Alzheimer Yes No Kyphosis Yes No
Amyotrophic Lateral Sclerosis Yes No Liver Dysfunction Yes No
Anorexia or Bulimia Yes No Kidney Failure, or Dysfunction Yes No
Anxiety Disorder Yes No Malignancy If yes, describe below Yes No
Arteriovenous Malformations (AVMs) Yes No
Arthritis Yes No
Asthma Yes No Mania Yes No
Autoimmune Disease Yes No Muscular Dystrophy Yes No
Bipolar Disorder Yes No Myocardial Infarction (Heart Attack) Yes No
Bleeding Disorder Yes No Narcolepsy Yes No
Cataracts Yes No Obstructive Sleep Apnea Yes No
Cerebrovascular Accident (Stroke) Yes No Organ Transplant If yes, describe Yes No
Chemotherapy If yes, state when Yes No
Osteoporosis Yes No
Claudication Yes No Pancreatitis Yes No
Clotting Disorder Yes No Periodic Limb Movement Disorder Yes No
Congenital Heart Defects Yes No Peripheral Artery Disease Yes No
Coronary Artery Disease Yes No Personality Disorder Yes No
COPD Yes No Pituitary Dysfunction Yes No
Cystic Fibrosis Yes No Polycystic Ovarian Syndrome Yes No
Depression Yes No Pulmonary Artery Hypertension Yes No
Diabetes Yes No Pulmonary fibrosis Yes No
Dialysis Yes No Radiation Therapy If yes, explain Yes No
Eclampsia or Pre-eclampsia Yes No
Endocarditis Yes No Recurrent Infections Yes No
Endometriosis Yes No Restless Leg Syndrome Yes No
End Stage Renal Disease Yes No Sarcoidosis Yes No
Erectile Dysfunction Yes No Schizophrenia Yes No
Esophageal Dysfunction Yes No Scleroderma Yes No
Fibromyalgia Yes No Scoliosis Yes No
Gallstones Yes No Seizure Disorder Yes No
Gastritis or Gastric Ulcers Yes No Sickle Cell Yes No
GERD (reflux problems) Yes No Sjogren Yes No
Glaucoma Yes No Skin Disorders (Psoriasis, Acne) Yes No
Heart or Valve Defects Yes No Thalassemia Yes No
Hemochromatosis Yes No Thrombocytopenia Yes No
Hemorrhoids Yes No Thrombophilia Yes No
Hepatitis Yes No Transfusions Yes No
HIV or AIDS Yes No Tuberculosis Yes No
Hypertension Yes No If yes, have you been treated? Yes No
Hyperthyroidism Yes No Urinary retention or urgency Yes No
Hypotension Yes No Vasculitis Yes No
Hypothyroidism Yes No Visual defects Yes No
Inflammatory Bowel Disease Yes No Vocal cord dysfunction/paralysis Yes No

MB & RR 2008 e-medtools.com The information on this page was reviewed with the patient HCC Initials _____ HCP Initials _____ 5
Health Care Consumer Questionnaire Patient DOB Date
Review of Systems
In the last 6 months have you experienced the following symptoms. Check either “yes” or “no” for each symptom.
Constitutional Genitourinary
Weight Loss or Gain Yes No Blood in your urine Yes No
Appetite changes (increased or decreased) Yes No Menstrual changes Yes No
Fatigue, profound and impairs daily function Yes No Urinating that is painful or difficult Yes No
Fever Yes No Erection problems Yes No
Shakes/sweats from lack of alcohol or drug Yes No Vaginal discharge or bleeding Yes No
Eyes Musculoskeletal
Eye pain or drainage Yes No Broken bones Yes No
Visual changes Yes No Joint pain or swelling Yes No
Dry, irritated eyes Yes No Muscle aches Yes No
ENT/Mouth Muscle weakness Yes No
Ear pain or drainage Yes No Back pain Yes No
Frequent sinus infections Yes No Skin/Breasts
Hearing changes or loss Yes No Masses or lumps Yes No
Nosebleeds Yes No Nipple discharge Yes No
Dizziness Yes No Rashes or nonhealing ulcers Yes No
Respiratory Neurologic
Blood in your sputum Yes No Seizures Yes No
Chest tightness Yes No Coughing or choking with swallowing Yes No
Cough lasting >1 month, productive or not Yes No Excessive daytime sleepiness Yes No
Shortness of breath Yes No Extremity pain or burning sensations Yes No
Wheezing Yes No Hallucinations Yes No
Chest pain with inhalation or coughing Yes No Numbness or tingling Yes No
Cardiovascular Difficulty falling asleep, staying asleep Yes No
Chest pain or heaviness Yes No Endocrinologic
Palpitations Yes No Hair loss Yes No
Fainting or near fainting spells Yes No Frequent urination Yes No
Swelling of feet or legs Yes No Increased thirst Yes No
Shortness of breath lying flat in bed Yes No Heat or cold intolerance Yes No
Gastrointestinal Heme/Lymph
Abdominal pain Yes No Bleeding from gums or nose Yes No
Blood in your stool Yes No Unexplained bruising Yes No
Constipation Yes No Night Sweats Yes No
Diarrhea or Food Intolerance Yes No Swollen, painful lymph nodes Yes No
Heartburn or Indigestion Yes No Allergy/Immun
Vomiting or nausea lasting for >1 day Yes No Watery eyes Yes No
Swallowing difficulty Yes No Runny nose Yes No
Psych Food intolerance Yes No
Anxiety without clear explanation Yes No Frequent skin sores Yes No
Sadness lasting for days or weeks Yes No
Hearing voices Yes No
Thoughts of hurting yourself Yes No
Thought of hurting others Yes No
Fear of people, places or things Yes No

MB & RR 2008 e-medtools.com The information on this page was reviewed with the patient HCC Initials _____ HCP Initials _____ 6
Health Care Consumer Questionnaire Patient DOB Date
Family Medical History Please list all known medical problems in your family.
(Specify M=Mother, F=Father, B=Brother, S=Sister, So=Son, D=Daughter, GM=Grandmother, GF=Grandfather)
Medical Problem Relative Medical Problem Relative

Additional Information that you feel may be helpful for your health care provider to know.

Health Care Provider Notes

Referral Information – We would appreciate learning how you heard about us? Check one, please
Another physician, nurse practitioner or physician assistant?
If so, please specify who:
Family member or friend who is a patient of this clinic
Family member or friend who is NOT a patient of this clinic
Sign outside your office
Billboard Ad
Media Ad Please specify Television Radio Newspaper Ad
Hospital referral service
Phone book
Internet
Other, please specify

MB & RR 2008 e-medtools.com The information on this page was reviewed with the patient HCC Initials _____ HCP Initials _____ 7

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New Patient Form

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New Patient Form

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Health Care Consumer Questionnaire Patient DOB Date

Patient Name Date

Describe the means by which you prefer to learn new information

Please list and describe your hobbies

Do you drink alcohol? Yes No #Drinks Day Week

Do you keep firearms in your residence? Yes No

Health Care Provider Notes

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Do you drink alcohol? Yes No #Drinks Day Week

Do you keep firearms in your residence? Yes No