First Name:
Last Name:
Age:
Date of Birth:
Preferred name:
Visit date:
Pronouns:
he/him/his
she/her/hers
they/them/theirs
decline to answer
other
Please describe:
Who referred you to our office?
Primary Care Physician:
What is your
Main Reason
for your visit:
How long has this problem existed:
ALLERGIES/SENSITIVITIES TO MEDICATIONS:
None
CURRENT MEDICATIONS WITH DOSAGE:
None
Preferred Pharmacy Name & Cross Streets:
Preferred Pharmacy Phone #:
Falls - for patients 65 and above
Have you fallen since your last visit or within the last year? If yes, did the fall result in injury?
Falling includes unintentionally coming to rest on the ground or other level such as a chair.
No
Yes, without injury
Yes, with injury
Please explain:
In the past 12 months, have you been worried or afraid that you might fall?
No
Yes
Please explain:
Influenza Screening
Have you received the flu vaccine since August 1?
No
Yes
Cannot receive due to medical contraindication
Past Medical History
None
Allergies
Yes
No
Anemia
Yes
No
Anxiety
Yes
No
Asthma
Yes
No
Bleeding disorder
Yes
No
Cancer
Yes
No
Depression
Yes
No
Diabetes mellitus
Yes
No
GERD (Reflux)
Yes
No
Hearing loss
Yes
No
Heart attack
Yes
No
Heart disease
Yes
No
High blood pressure
Yes
No
High cholesterol
Yes
No
HIV/AIDS
Yes
No
Kidney disease
Yes
No
Liver disease
Yes
No
Pneumonia/Lung disease
Yes
No
Psychiatric disorder
Yes
No
Salivary duct stone
Yes
No
Seizures
Yes
No
Sinus disorder
Yes
No
Sleep apnea
Yes
No
Speech delay
Yes
No
Stomach ulcers
Yes
No
Stroke
Yes
No
Thyroid disease
Yes
No
Tuberculosis
Yes
No
OTHER MEDICAL PROBLEMS:
PAST SURGICAL HISTORY
None
Adenoidectomy
Yes
No
Bronchoscopy
Yes
No
Cardiac surgery
Yes
No
Dental surgery
Yes
No
Ear surgery
Yes
No
Ear tubes
Yes
No
Esophagus surgery
Yes
No
Eye surgery
Yes
No
Facial cosmetic surgery
Yes
No
Nasal/Sinus surgery
Yes
No
Neck surgery
Yes
No
Orthopedic surgery
Yes
No
Salivary gland surgery
Yes
No
Throat surgery
Yes
No
Thyroid surgery
Yes
No
Tonsillectomy
Yes
No
OTHER SURGICAL HISTORY:
FAMILY HISTORY
None
Allergies
Mother
Father
Sister
Brother
Child
Anesthesia problems
Mother
Father
Sister
Brother
Child
Asthma
Mother
Father
Sister
Brother
Child
Bleeding disorder
Mother
Father
Sister
Brother
Child
Cancer
Mother
Father
Sister
Brother
Child
Diabetes
Mother
Father
Sister
Brother
Child
Genetic disease
Mother
Father
Sister
Brother
Child
Hearing loss
Mother
Father
Sister
Brother
Child
Heart disease
Mother
Father
Sister
Brother
Child
High blood pressure
Mother
Father
Sister
Brother
Child
Kidney disease
Mother
Father
Sister
Brother
Child
Psychiatric illness
Mother
Father
Sister
Brother
Child
Stroke
Mother
Father
Sister
Brother
Child
Sudden death
Mother
Father
Sister
Brother
Child
SOCIAL HISTORY
Smokeless Tobacco (chew/snuff):
Current user
Former user
Never used
Tobacco use:
Current smoker
Former smoker
Never smoked
Type of Use
-- Select --
Cigarettes
Pipe
Cigars
Vape
E-Cigarettes
Amount per day
How long?
When did you quit?
Alcohol:
Yes
Not currently
Never
Recreational drugs:
Yes
Not currently
Never
Occupation:
FEMALE PATIENTS
Are you pregnant OR trying to get pregnant?
Yes
No
REVIEW OF SYMPTOMS
None
Decreased appetite
Fatigue
Fever/chills/night sweats
Unintended weight loss
Vision changes
Eye pain
Chest pain
Difficulty breathing
Cough
Nausea/vomiting
Change in bowel habits
Skin rash
Mental status changes
Weakness
Numbness
Dizziness
Headache/migraine
Heat/cold intolerance
Bleed easily
Bruise easily
FORM COMPLETED BY:
The above information is accurate to the best of my knowledge.
Form completed by:
Date:
Signature: