We specialize in you

“We specialize in you”
□ New Patient
□ Information Update
Date: ___________________
(Paciente Nuevo)
(Cambio de Info)
(Fecha)
PLEASE PRINT (Letra De Molde)
Acct #:_______________________
Referred by: _____________________________
Patient Last Name: _________________________________First Name:_________________________________ Middle Initial: __________________________
(Apellido)
(Primer Nombre)
(INIC.)
Street Address: ___________________________________________________ City: __________________________
(Domicillio)
(Ciudad)
State:_________ Zip: ________________
(Estado)
(Zona Postal)
Home Number: __________________________ Secondary Phone Number: _____________________________ Work Phone:___________________________
(Telfono)
(Telefono Mobile)
(Numero de Trabajo)
Email: __________________________________ Sex: ___M ___F Birthdate: _________________ Social Security Number: ____________________________
(Correo Electronico)
(Sexo)
(Fecha De Nac)
(Seguro Social)
In Case of Emergency Notify: (En Caso De Emergencia Notifique A’)
Last Name: ____________________________________ First Name: __________________________________ Relationship: __________________________
(Apellido)
(Primer Nombre)
(Parentesco)
Street Address: ___________________________________________________ City: __________________________
(Domicillio)
(Ciudad)
State:__________ Zip: _______________
(Estado)
(Zona Postal)
Home Number: __________________________ Secondary Phone Number: _____________________________ Work Phone:___________________________
(Telfono)
(Telefono Mobile)
(Numero de Trabajo)
NEW PATIENT HEALTH QUESTIONAIRE:
1) Are you allergic to any medications?: □ Yes □ No __________________________________________________________________________
2) Are you allergic to anything else?: □ Yes □ No _____________________________________________________________________________
3) Do you smoke? □ Yes □ No
How many cigarettes/packs a day? ________________
4) Do you drink alcohol? □ Yes □ No
How many drinks a week?________________________
5) What are your current medications? (please include any vitamins or supplements)
___________________________
____________________________
____________________________
_______________________
___________________________
____________________________
____________________________
_______________________
6) What brought you in today? ____________________________________________________________________________________________
7) Do you have any current medical problems?: _______________________________________________________________________________
8) Previous hospitalizations?: _____________________________________________________________________________________________
9) Please mark if you have/had the following:
□ Heart Disease
□ Diabetes
□ Asthma
□ Stroke
□ Alcoholism
□ Cancer
□ Heart Murmur
□ Liver Disease
□ Thyroid Problems □ Kidney Disease
□ Elevated Cholesterol
□ Depression
□ Broken Bones
□ Rheumatic Fever □ Tuberculosis
□ Knocked Unconscious
Please describe if you answered yes to any of the above: ________________________________________________________________________
10) Please mark if you have a family history of the following, and if so, who?:
□Heart Attack: ______________________
□Elevated Cholesterol: ____________________
□Seizures: _____________________
□Depression: ______________________
□High Blood Pressure: ____________________
□Diabetes: _____________________
□Glaucoma: ______________________ □Asthma/Allergies:
_____________________
□Stroke: ______________________
□Alcoholism: ______________________ □Liver Disease:
_______________________
□Cancer: _______________________
□Arthritis:_________________________ □Kidney Disease:
_______________________
□Tuberculosis: ___________________
□Anemia:_________________________ □Thyroid Problems:_______________________
□Mental Illness: __________________
Please describe if you answered yes to any of the above: ________________________________________________________________________