Dr. Gerald B Harris, II

Available Forms

Consent/Release Form Contract for Long-Term Controlled Substances Therapy for Chronic Pain and/or Dependence/Addiction Financial Policy Insurance Information New Patient - Registration New Patient - System Review Referral Form Weekly Blood Pressure Log Well-Woman Exam New Patient - Health History Questionnaire New patient - Alcohol Screening Test New patient - Depression Screening Pain Assessment New patient - Drug Abuse Screening Test (DAST) Therapy Progress Report Well Man Exam

New Patient - Health History Questionnaire

Last Name *

First Name *

Date of Birth *

Childhood Illness: *

Mumps

Measles

Rubella

Chicken Pox

Rheumatic Fever

None of the above

Check all that apply.

Have you ever been diagnosed with any of the following? *

Check all that apply.

Review of Symptoms (check all symptoms you are concerned about that have occurred in the last month) *

Check all that apply.

Other:

Do you have any ALLERGIES to FOODS? *

Yes

If yes, please list:

Social History

Occupation

Are you retired?

Yes

Marital Status

Do you have any biological children? *

yes

List age and gender of all biological children

Alcohol Use *

One drink is equal to a 12 oz beer/wine cooler, 5 oz of wine or one 1.5 oz shot of spirits such as whiskey, vodka, brandy or rum

Tobacco Use *

Age or year quit smoking

How many years did you or have you smoked

Amount smoked per day

Exercise *

Exercise is 30 minutes of cardiovascular activity

What do you do for exercise?

IV/Illicit Drug Use

Do you wear your seat-belt when riding in a vehicle? *

Yes

Are you at risk for domestic violence?

Yes

List any surgeries and the year performed

Do you have any ALLERGIES to any MEDICATIONS? *

Yes

If yes, Please list medication and reaction

List ALL prescribed and over-the-counter medications you currently take

Please include the name of the medication, strength, and how often you take it.

Health Maintenance

Date of Last Physical Exam

Date of last Colonoscopy

Date of last PSA

Date of last Pap Smear

Date of last Mammogram

Date of last Chest X-ray

Family Health History

List Father's Health Problems

Is your Father still living?

Yes

If no longer living, at what age did your father pass?

List Mother's Health Problems

Is your Mother still living?

Yes

If no longer living, at what age did your mother pass?

How many biological brothers do you have? *

List Health Problems for all brothers, if applicable

How many biological sisters do you have? *

List Health Problems for all sisters, if applicable

List Health Problems for all children, if applicable

* Required field