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New Patient Medical Questionnaire

DATE:

Patient Name: DOB: AGE:

Other Physicians:

Who can we thank for referring you to our practice?

Pharmacy Name & Location:` Phone #

What problems are you here for today?

Please check any of the following disorders that you HAVE or HAVE HAD, and indicate the year it was first identified.

CARDIAC: Yes No Angina (heart pain) _

Yes No Heart Attack _ Yes No Abnormal Heart Valve(s) _ Yes No Coronary Artery Disease _ Yes No Mitral Valve Prolapse Yes No Heart Failure _

Yes No Cardiomyopathy _ Yes No Pericarditis Yes No Cardiomegaly (Enlarged Heart) Yes No Pacemaker

Yes No Implantable Defibrillator Yes No Rheumatic Fever _

Yes No Heart Murmur Yes No Arrhythmia / Abnormal Rhythm

VASCULAR: Yes No Stroke or TIA (mini-stroke)

Yes No Renal(kidney) Artery Disease

Yes No Pulmonary Embolism (clots in lungs)

Yes No Peripheral(leg or arm)Artery Disease_ _ Yes No Other type of Vascular Disease

Yes No DVT (clots in leg)_ _

Yes No History of aneurysm

CHIEF COMPLAINT

CARDIAC PROBLEM LIST

2

New Patient Medical Questionnaire DATE: _____

Patient Name: DOB: AGE:

Please list ALL medications that you are taking at home. Include ALL prescription medications, non-prescription medications, vitamins, herbal remedies and supplements

Name of Medication

Example Lasix Dose/Strength How

40 mg

Many/How Often/When

twice a day - morning and night

1)

2)

3)

4)

5)

6)

7)

8)

9)

10)

11)

12)

13)

14)

15)

(Please attach additional pages if necessary)

Please list any medications, foods, or materials such as contrast dye or iodine that you are allergic to, had an adverse reaction to or do not tolerate and describe the reaction.

Medication Reaction (e.g. hives, swelling, short of breath, rash, etc.)

Reviewed By:

CURRENT MEDICATIONS / SUPPLEMENTS Yes No

ALLERGIES / INTOLERANCES TO MEDICATIONS Yes No

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New Patient Medical Questionnaire DATE:

Patient Name: DOB: AGE:

Please check any of the following disorders that you HAVE or HAVE HAD, and indicate the year it was first identified

PULMONARY: Yes No Asthma

Yes No Emphysema / COPD_

Yes No Pneumonia

Yes No Bronchitis

Yes No Tuberculosis

Yes No Sleep Apnea

GASTROINTESTINAL: Yes No Reflux (GERD)_

Yes No Diverticulosis / Diverticulitis

Yes No Liver Disease / Hepatitis_

Yes No Gallbladder Disease / Gallstones

Yes No Hiatal Hernia_

Yes No Ulcers

Yes No Gastritis

Yes No Gastrointestinal Bleed_

RENAL/GENITOURINARY Yes No Dialysis

Yes No Kidney Stones_

Yes No Prostate Disease

Yes No Kidney Disease /Elevated Creatinine

NEUROLOGICAL / PSYCHOLOGICAL: Yes No Intracranial (in the brain) Bleeding

Yes No Migraine Headaches

Yes No Depression

Yes No Seizure Disorder

Yes No Dementia_ _

Yes No Anxiety Disorder

FEMALE REPRODUCTIVE: Not Applicable Yes No Multiple Miscarriages_

Yes No Menopause (at what age?)

Yes No Currently Pregnant (# of weeks)

ENDOCRINE: Yes No Thyroid Disorder Yes No Adrenal Disorder

OTHER: Yes No Anemia Yes No Bleeding Disorder_

Yes No Clotting Disorder Yes No Gout _

Yes No Ambulate with assistance

Yes No HIV

Yes No Vertigo

Yes No Cancer (type?)_

Yes No Autoimmune Disorders (i.e.Lupus)

Yes No Previous weight loss meds (i.e. Fen Phen)_

Yes No Osteoporosis Arthritis

Yes No Rheumatoid Arthritis

Please list any other health problems that are not on the list:

PAST MEDICAL HISTORY

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Please list any surgeries you have had and include the year and location.

Surgery Date Surgeon Location

Example: Gallbladder Removed 1980 Dr. Frank Smith Parkland, Dallas

Marital Status?: Single Married Divorced Separated Widowed Domestic Partner Previously Widowed-

Number of sons?:_ Number of daughters?:

Current hometown?

With whom do you live?

Do you have a Medical Power of Attorney? Yes No

Who? Advanced Directives? None Do Not Resuscitate

Healthcare Proxy Living Will Date: Are you retired?: Yes No Current or Previous

Occupation:

Leisure activities?: (Include any hobbies)_

Home exercise equipment? Yes No If yes, what types_

Home blood pressure monitor? Yes No If yes, average readings:

SOCIAL HISTORY:

SURGICAL HISTORY / OPERATIONS Yes No

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Do you use tobacco? Yes Formerly Never

Type: How much: Start/Quit Dates

Cigarettes _ per day Years Smoked?_ Quit Date? Cigars _ per day Years Smoked?_ Quit Date? Pipes _ per day Years Smoked?_ Quit Date?

Chewing tobacco _ per day Years Used? Quit Date?

Do you use alcohol? Yes Formerly Never

Describe your use?

Rarely Social Daily Frequently Occasional Quit (when)_

Type: How much:

Beer _ cans per day / wk / mo /

Wine _ glasses per day / wk / mo / yr

Spirits _ glasses per day / wk / mo / yr

Do you use caffeine? Yes Formerly Never

Type:

Caffeinated Coffee? cups per day / wk / mo / yr Quit (when)

Caffeinated Tea? cups per day / wk / mo / yr Quit (when)

Caffeinated Soda? cans per day / wk / mo / yr Quit (when)

Chocolate? servings per day / wk / mo / yr Quit (when)

Do you use recreational drugs? Yes Formerly Never

Type: How much: Start/Quit Dates

Marijuana per day wk mo yr When did you start? Quit? Rehab?

Cocaine per day wk mo yr When did you start? Quit? Rehab?

Methamphetamine per day wk mo yr When did you start? Quit? Rehab?

Exercise No/Sedentary Occasional Regular Active Lifestyle Physically unable to exercise

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Please indicate below if you Father, Mother or Sibling(s) have or have had the following diagnoses by providing the age when it was diagnosed.

Cancer: Father - at age Mother - at age

Sister(s) - at age

Brother(s) - at age

Hypertension: Father - at age

Mother - at age

Sister(s) - at age

Brother(s) - at age

Diabetes: Father - at age

Mother - at age

Sister(s) - at age

Brother(s) - at age

Cholesterol: Father - at age

Mother - at age

Sister(s) - at age

Brother(s) - at age

Heart Failure / Cardiomyopathy: Father - at age

Mother - at age

Sister(s) - at age

Brother(s) - at age

Stroke: Father - at age

Mother - at age

Sister(s) - at age

Brother(s) - at age

Blood Clots: Father - at age

Mother - at age

Sister(s) - at age

Brother(s) - at age

Aneurysm-: Father - at age

Mother - at age

Sister(s) - at age

Brother(s) - at age

UNKNOWN NONE

Died at age

Died at age

Died at age

Died at age

Died at age _

Died at age

Died at age

Died at age

Died at age

Died at age

Died at age

Died at age

Died at age

Died at age

Died at age

Died at age

Died at age

Died at age

Died at age

Died at age

Died at age

Died at age

Died at age

Died at age

Died at age

Died at age

Died at age

Died at age

Died at age

Died at age

Died at age

Died at age

Were You Adopted? Yes No

Reviewed By:

FAMILY HISTORY: