First Name:
Last Name:
Date of Birth:
Chosen name:
Visit date:
Pronouns:
he/him/his
she/her/hers
they/them/theirs
decline to answer
Other
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
Hay fever / Environmental allergies
Yes
No
Asthma
Yes
No
Pneumonia/Lung disease
Yes
No
Food allergy
Yes
No
Wasp / bee sting allergy
Yes
No
Drug allergy
Yes
No
Anaphylactic reaction
Yes
No
Eczema
Yes
No
Hives
Yes
No
Latex allergy
Yes
No
Sinus disorder
Yes
No
Frequent infections
Yes
No
Hearing loss
Yes
No
Heart attack
Yes
No
Heart disease
Yes
No
High blood pressure
Yes
No
High cholesterol
Yes
No
Bleeding disorder
Yes
No
HIV/AIDS
Yes
No
Kidney disease
Yes
No
Liver disease
Yes
No
Cancer
Yes
No
Diabetes mellitus
Yes
No
Seizures
Yes
No
Anemia
Yes
No
Sleep apnea
Yes
No
Stomach ulcers
Yes
No
Stroke
Yes
No
Thyroid disease
Yes
No
Tuberculosis
Yes
No
Acid reflux (GERD)
Yes
No
Autoimmune disorder
Yes
No
OTHER MEDICAL PROBLEMS:
PAST SURGICAL HISTORY
Past surgical history:
FAMILY HISTORY
None
Environmental allergies
Parent 1
Parent 2
Sibling 1
Sibling 2
Child
Eczema
Parent 1
Parent 2
Sibling 1
Sibling 2
Child
Asthma
Parent 1
Parent 2
Sibling 1
Sibling 2
Child
Medication allergy
Parent 1
Parent 2
Sibling 1
Sibling 2
Child
Cancer
Parent 1
Parent 2
Sibling 1
Sibling 2
Child
Diabetes
Parent 1
Parent 2
Sibling 1
Sibling 2
Child
Angioedema
Parent 1
Parent 2
Sibling 1
Sibling 2
Child
Immunodeficiency
Parent 1
Parent 2
Sibling 1
Sibling 2
Child
Autoimmune disorder
Parent 1
Parent 2
Sibling 1
Sibling 2
Child
Heart disease
Parent 1
Parent 2
Sibling 1
Sibling 2
Child
High blood pressure
Parent 1
Parent 2
Sibling 1
Sibling 2
Child
Kidney disease
Parent 1
Parent 2
Sibling 1
Sibling 2
Child
Psychiatric illness
Parent 1
Parent 2
Sibling 1
Sibling 2
Child
Stroke
Parent 1
Parent 2
Sibling 1
Sibling 2
Child
Sudden death
Parent 1
Parent 2
Sibling 1
Sibling 2
Child
Thyroid disease
Parent 1
Parent 2
Sibling 1
Sibling 2
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 use:
Yes
Not currently
Never
Recreational drug use:
Yes
Not currently
Never
Occupation:
Work Environment:
Office
Other indoor
Outdoor
Other
Pets or other exposures on-site?
How do you get to work:
Car
Public Tansit
Cycle
Other
FEMALE PATIENTS
Are you pregnant OR trying to get pregnant?
Yes
No
ENVIRONMENTAL SURVEY
Who do you live with?
Does anyone in your household smoke?
Yes
No
Visible mold or mold odors in the home?
Yes
No
Is there wall to wall carpeting?
Yes
No
Do you use humidifiers?
Yes
No
Any rodent or cockroach infestation?
Yes
No
Pets?
Cat
Dog
Other
None
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
Bleed easily
Bruise easily
Joint pain/swelling
Heat intolerance
Cold intolerance
Frequent urination
FORM COMPLETED BY:
The above information is accurate to the best of my knowledge.
Form completed by:
Date:
Signature: