Emmanuel Family Practice Associates

NOTE: This form is for NEW patients only who have not yet completed the patient history form in our office. Existing patients do not need to complete this form.

PATIENT INFORMATION

Last Name * First Name * Middle Name Date of Birth *

REVIEW OF SYSTEMS (Check any that apply at present, or in the recent past)

Review of Symptoms If travel out of USA, Where? Women: # of times pregnant Women: # of Children

HEALTH MAINTENANCE (Please provide approximate dates)

Last Tetanus Shot Last Mammogram Last PAP test Last Hepatitis B Vaccine Last Pneumonia Vaccine Last Prostate Exam Last Chicken Pox or Shingles Vaccine Last Flu Shot Which of the following tests have you had in the last 5 years?

SOCIAL HISTORY

Who lives in your household? Do you smoke? * How may times per day do you smoke? How many years have you smoked? Do you chew tobacco? * If you chew tobacco, how much per day? If you chew tobacco, how many years? Do you drink alcohol? * If yes, how many drinks per day? If yes, how many drinks per month?

RISK PREVENTION - Do you?

Wear seat belts? * Wear helmet (if riding bike/motorcycle)? * Practice Safe Sex? * Want an HIV (AIDS) blood test? * Have an abusive partner or unsafe living situation? * Have a Living Will? * Have a "Health Care Power of Attorney"? * If no, would you like information? Have an organ donor card? *

CURRENT MEDICATIONS

Medications: Specify medication NAME, DOSE (strength), and Instructions

ALLERGIES

Medication Allergies * Environmental Allergies * Food and Other Allergies *

HOSPITALIZATIONS & SURGERIES

Hospitalization & Surgeries

FAMILY HISTORY

Mother * Mother: Please list medical problems, if applicable Father * Father: Please list medical problems, if applicable Maternal Grandmother * Maternal Grandmother: Please list medical problems, if applicable Maternal Grandfather * Maternal Grandfather: Please list medical problems, if applicable Paternal Grandmother * Paternal Grandmother: Please list medical problems, if applicable Paternal Grandfather * Paternal Grandfather: Please list medical problems, if applicable Sibling 1 Sibling 1 Sibling 1: Please list medical problems, if applicable Sibling 2 Sibling 2 Sibling 2: Please list medical problems, if applicable Sibling 3 Sibling 3 Sibling 3: Please list medical problems, if applicable Sibling 4 Sibling 4 Sibling 4: Please list medical problems, if applicable Child 1 Child 1 Child 1: Please list medical problems, if applicable Child 2 Child 2 Child 2: Please list medical problems, if applicable Child 3 Child 3 Child 3: Please list medical problems, if applicable Child 4 Child 4 Child 4: Please list medical problems, if applicable Does anyone in your family have the following conditions? If anyone in your family has or had cancer, what kind?