NEW PATIENT INTAKE FORM

General Information

Elements marked * are required

First Name *

Last Name *

DOB *

Age *

Today's Date *

Last 4 Digits of SSN# *

Reason for Visit *

Referring Doctor

Primary Care Doctor

Medical History – Please check all that apply or have applied in the past *

List any additional medical problems and surgeries that you have had

Please list all known drug allergies

Have you ever taken any of the following? * Yes No

(Mark all that apply)

Estrogen Growth hormones Steroids Herbal supplements

Family History *

Please list anyone in your family who has had cancer. Please list their relationship to you, not their name. *

Family member with cancer

(ex. parents, siblings, paternal/maternal grandparents, maternal/paternal aunts and/or uncles, and cousins)

Type of cancer

Age at diagnosis

If alive current age,
if deceased age at death

Family member with cancer

(ex. parents, siblings, paternal/maternal grandparents, maternal/paternal aunts and/or uncles, and cousins)

Type of cancer

Age at diagnosis

If alive current age,
if deceased age at death

Family member with cancer

(ex. parents, siblings, paternal/maternal grandparents, maternal/paternal aunts and/or uncles, and cousins)

Type of cancer

Age at diagnosis

If alive current age,
if deceased age at death

Family member with cancer

(ex. parents, siblings, paternal/maternal grandparents, maternal/paternal aunts and/or uncles, and cousins)

Type of cancer

Age at diagnosis

If alive current age,
if deceased age at death

Have you ever had any genetic testing? * Yes No

Year

Results

Have any family members had testing? * Yes No

Who and results?

Are you of Ashkenazi Jewish descent? * Yes No

Mother or father’s side?

Social History *

Alcohol use

Never Socially Daily (# drinks/day)

Current tobacco use

Yes No Former Smoker Quit Date

If you currently smoke

# cigarettes/day: # of years

Occupation:

Medications List

Elements marked * are required

Please list all medications that you are currently taking.
Include all over-the-counter medicines, vitamins and herbal supplements.

Please list all known drug allergies

Pharmacy Name*

Pharmacy Location*

Pharmacy Phone Number*

Please bring all the medication bottles with you to your appointment so we can do a thorough review of your medications.

Name of Medication

Brand or Generic Name

Strength/Dosage

mg, units, puffs or drops

Directions

How many times per day? Only as needed?

10.

11.

12.