Elements marked * are required

 Address *

 Phone Number *

 Emergency Contact Name and Number *

 Gender at Birth *

 Gender Identity

 Referring Doctor *

 Primary Care Doctor

 Problem or reason for your visit

 List any known allergies to medications or other substances:  *

 What type of reaction do you have?

 Email Address

 Your Primary Language

 Communication Barriers    
 Deaf    
 Hard of Hearing    
 Blind    
 Difficulty Seeing    
 Mute    
 Other

 If other communications issues please describe

 Interpreter Needed?     Yes     No

 Race     American Indian/Alaskan Native      Asian      Black/African American      White      Native Hawaiian/Pacific Islander      More than one Race      Other

 Ethnicity     Hispanic or Latino      Not Hispanic or Latino

 Would you like to identify a religious preference?      Yes      No

 If necessary, would you agree to have a blood transfusion?  *    Yes      No

 Do you have any medical advance directives? *      Yes      No

 If yes, what type?     Living Will      Power of Attorney      Healthcare Surrogate

 Do you use tobacco?      Yes     No
 Quit/Year

 If you answered “Yes” or “Quit” above, what type?     Chewing     Cigar     Cigarettes     Pipe     Smokeless/Vaping    

 Number of years used

 How many per day?

 Do you drink alcohol?       Yes      No

 

 If “Yes,” how often?     Daily     Weekly      Occasionally

 

 Do you consume caffeine?     Yes      No

  If “Yes,” what type?     Chocolate      Coffee      Soda      Tablets      Tea

 Do you have a past or current history of recreational drug use?      Yes      No

 What is your occupation status?       Employed       Retired       Student       Unemployed       Unspecified     

 What is your occupation?

 Who do you live with?

 Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering,or making decisions? 
    Yes      No

 Do you have serious difficulty walking or climbing stairs? 
    Yes      No

 Do you have difficulty dressing or bathing? 
    Yes      No

 Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping? 
    Yes      No

 Colonoscopy Date

 Mammogram Date

 Bone Density/Dexa Scan Date

 Pap Smear Date

 Pelvic Exam Date

 

 Any recent testing?

 Which testing facility?

 Past cancer diagnosis?

 Date

 Cancer Diagnosis

 Treating Doctor

 Which Hospital? (if admitted)

 Any recent hospitalizations?      Yes      No

 Hospitalization Date

 Hospital Name

 For patients born female - Age of menarche (first menstrual cycle)

 Date of last menstrual period

 Number of Pregnancies

 Number of Deliveries

 Number of Lost Pregnancies

 Number of Living Children

 Abnormal Bleeding

 AIDS/HIV

 Anemia

 Angina/Heart Disease/Murmur

 Anxiety

 Arthritis/Osteoarthritis

 Asthma

 Atrial Fibrillation

 Bladder Problems

 Blood Clots (leg, lung)

 Blood Disorders

 Bowel Problems

Bowel Problem Details

 Breast Lumps

 Cancer

Cancer Type

 Cough

 COPD

 CVA/Stroke

 Coronary Artery Disease

 Defibrillator

 Depression

 Diabetes

 Eye Disorders

 Frequent Infections

 GERD

 Glaucoma

 Headaches

 Hepatitis B

 Hepatitis C

 High Blood Pressure

 High Cholesterol

 Irregular PAP Smear

 Kidney Problems

 Liver Disease

 Low Blood Pressure

 Lung Problems

 Migraines

 Neurological Disorders

 Obesity

 Open Sores/Wounds

 Pacemaker

 Peptic Ulcer Disease

 Psychiatric Issues

 Renal Disease

 Seizure Disorder

 Thyroid Disease

 Unusual Lumps

 Other issues not listed above

 Other Surgical History

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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

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