New Patient Questionnaire

Name_____________________________________ Age ________ Sex F M Date_________
Are you: Married Separated Divorced Widowed Single Partnership
How did you hear about the clinic? _____________________________
When and where did you receive your last health care?_______________________________________________
_____________________________________________________________________________________
What was the reason?________________________________________________________________________
Please list in order of importance, your health problems:
1. _____________________________________________________________________________________
2. _____________________________________________________________________________________
3. _____________________________________________________________________________________
4. _____________________________________________________________________________________
5. _____________________________________________________________________________________
FAMILY HISTORY Y=yes N=no P=past
Have any member had any of the following? If yes specify family member.
Anemia Y N P _______________________________________________
Asthma, Hay fever Y N P _______________________________________________
Cancer Y N P _______________________________________________
Diabetes Y N P _______________________________________________
Epilepsy Y N P _______________________________________________
Glaucoma Y N P _______________________________________________
Heart Disease Y N P _______________________________________________
High Blood Pressure Y N P _______________________________________________
Kidney Disease Y N P _______________________________________________
Mental Illness Y N P _______________________________________________
Pneumonia Y N P _______________________________________________
Stroke Y N P _______________________________________________
Tuberculosis Y N P _______________________________________________
Were any of these the cause of death? If so which family member and what was their age at time of death.
_____________________________________________________________________________________
CHILDHOOD ILLNESSES
Scarlet Fever Y N Diphtheria Y N Rheumatic fever Y N
Mumps Y N Measles Y N German Measles Y N

IMMUNIZATIONS
Polio Y N Diphtheria Y N Rubella Y N
Pertussis Y N Measles/Mumps Y N Hepatitis B Y N
Tetanus Y N Date of last Tetanus _________________________________
ALLERGIES
What Drugs are you allergic to? _____________________________________________________________
What Foods? _____________________________________________________________
Any environmental Allergens? _____________________________________________________________

Have you ever been hospitalized? Y N If so, what was the reason and when.
_____________________________________________________________________________________
Have you had any surgeries? Y N If so what was the reason and when.
_____________________________________________________________________________________
CURRENT MEDICATIONS
Antidepressants Y N Heart Medication Y N Thyroid Y N
Antibiotics Y N Laxatives Y N Tranquilizers Y N
Antacids Y N Pain Relievers Y N Blood Pressure Y N
Cortisone Y N Sleeping Pills Y N Birth Control Y N
Please list any prescription medications, over the counter medications, vitamins or other supplements that you are taking.
_____________________________________________________________________________________
_____________________________________________________________________________________
Y=yes N=no P=condition in the past
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Skin
Acne Y N P Boils Y N P Color changes Y N P Eczema Y N P
Hives Y N P Itching Y N P Lumps Y N P Moles Y N P
Rashes Y N P Scaling/flaking Y N P
Head
Hair loss Y N P Headaches Y N P Head Injury Y N P Skull fracture Y N P
Eyes
Eye Pain Y N P Cataracts Y N P Double vision Y N P Dryness Y N P
Glasses/Contacts Y N P Glaucoma Y N P Impaired Vision Y N P Tearing Y N P
Ears
Discharges Y N P Earaches Y N P Dizziness Y N P Impaired hearing Y N P
Ringing Y N P Trauma Y N P
Nose and Sinus
Frequent colds Y N P Hay fever Y N P Nose Bleeds Y N P Sinus Pain Y N P
Stuffiness Y N P Persistent Runny Nose Y N P
Mouth and Throat
Bleeding Gums Y N P Difficulty swallowing Y N P Dental cavities Y N P
Frequent sore throat Y N P Hoarseness Y N P Sore tongue Y N P
Ulcerations Y N P Difficulty speaking Y N P
Neck
Goiter Y N P Lumps Y N P Trauma to neck Y N P Swollen glands Y N P
Respiratory
Asthma Y N P Bronchitis Y N P Cough Y N P Emphysema Y N P
Difficulty breathing Y N P Pain with breathing Y N P Pleurisy Y N P
Pneumonia Y N P Shortness of breath Y N P Tuberculosis Y N P
with lying down Y N P Spiting up blood Y N P at night Y N P
Wheezing Y N P with exertion Y N P
Cardiovascular
Angina Y N P Chest Pain Y N P Dizziness with standing Y N P
High blood pressure Y N P Heart Disease Y N P Murmurs Y N P
Palpitations Y N P Pain in leg on walking Y N P Rheumatic fever Y N P
Swelling of ankles Y N P
Gastrointestinal
Belching or passing gas Y N P Blood in stool Y N P Change in appetite Y N P
Change in thirst Y N P Gallbladder disease Y N P Heartburn Y N P
Hemorrhoids Y N P Jaundice Y N P Liver disease Y N P
Ulcers Y N P
Bowel movements: how often? ___________________ Is this a change Y N
Vomiting Y N P
Urinary
Frequent infections Y N P Frequency at night Y N P
Increased frequency Y N P Inability to hold urine Y N P
Kidney stones Y N P Kidney pain Y N P Painful urination Y N P
Urethral discharge Y N P
Female Reproductive system
Age menses began ______________ Birth Control Y N P
Average number of days __________ What type ____________________________
Length of cycle ________________ Number of pregnancies ________________
Are cycles regular Y N P Number of live births ________________
Painful menses Y N P Number of miscarriages ________________
Pain during intercourse Y N P Number of abortions ________________
Excessive flow Y N P Difficulty conceiving Y N P
Premenstrual syndrome Y N P Menopausal symptoms Y N
History of venereal disease Y N P Are you sexually active Y N P
Sexual difficulties Y N P
Sexual preference: Heterosexual _____ Bisexual ______ Homosexual ______

Breasts
Do you do breast self exam Y N P Lumps Y N P Pain Y N P
Nipple discharge Y N P
Male reproductive system
Hernias Y N P Are you sexually active Y N P Testicular pain Y N P
Sexual difficulties Y N P Testicular masses Y N P
Sexual preference: Heterosexual _____ Bisexual ______ Homosexual ______
Discharge or soreness Y N P Prostate disease/pain Y N P
Venereal disease Y N P
Musculoskeletal
Joint pain/stiffness Y N P Broken bones Y N P Swelling of joints Y N P
Muscle cramps or spasms Y N P Arthritis Y N P Weakness Y N P
Peripheral vascular
Coldness of hands/feet Y N P Varicose veins Y N P Deep leg pains Y N P
Numbness of hands/feet Y N P Paralysis Y N P
Neurologic
Dizziness Y N P Numbness or tingling Y N P Fainting Y N P
Loss of memory Y N P Seizures Y N P Paralysis Y N P
Endocrine/Blood
Anemia Y N P Excessive thirst Y N P Easy bleeding/bruising Y N P
Heat or cold intolerance Y N P Excessive hunger Y N P
Hypothyroid Y N P
Mental /emotional
Anxiety/Nervousness Y N P Excessive fears Y N P Depression Y N P
Mood swings Y N P Excessive anger Y N P Tension Y N P
Habits
Do you awaken rested Y N Sleep well Y N Average hours of sleep___________
What are your main hobbies/interests? ________________________________________
__________________________________________________________________________
Enjoy your work Y N Watch television Y N How many hours/day ______
Read Y N How many hours day ____________
What forms of exercise do you get and how often?______________________________________
_____________________________________________________________________________________
Take vacations Y N
Have you been treated for: Drug dependence Y N Alcohol abuse Y N
Do you use:
Recreational drugs Y N Alcoholic beverages Y N
Infants and Small Children
Eat well Y N Constipation Y N Sleep through night Y N
Colic Y N Ear aches Y N Hyperactive Y N
Frequent sore throat Y N Lethargic Y N Diarrhea Y N
Constant runny nose Y N Irritable Y N Skin rashes Y N
Abnormal Weight loss or gain Y N Behavioral problems Y N