F Parker Thornton MD LLC

NEW PATIENT HISTORY FORM

Full Name *

first, middle initial, last

Age *

Date of Birth *

Occupation *

Please list occupation, retired or student

Height *

Weight *

Referring Physician

Reason for Visit *

Please list all symptoms

Allergies: *

Please list all medication allergies, if none, please enter 'none'.

Current Medications

Please list or bring in printed list to your appointment.

Past Medical History

Cholesterol, hypertension etc.

Past Surgeries

Please list past surgeries (at any age)

Family History - If deceased, please comment on cause of death

Mother

Cause of death

Father

Cause of death

Siblings

Cause of death

Do you have a family history of any of the following: *

None of below

Heart disease

Diabetes

Stroke

High blood pressure

Cancer

Thyroid disease

Other family diseases or medical conditions

List any children or parent diseases not already mentioned.<br/>

Do you smoke *

yes

If yes, how much, how long?

Did you previously smoke? *

yes

If yes, when did you stop?

Do you use smokeless tobacco? *

yes

If yes, how often?

Do you drink alcohol? *

yes

If yes, how much & how often?

Do you use any illegal substances? *

yes

Do you exercise regularly?

yes

REVIEW OF SYSTEMS: Check ONLY if you have any personal history of any of these items.

Constitutional Symptons *

Good general health lately

Recent weight change

Decreased appetite

Fever/night sweats

Fatigue/weakness

Headaches

Not applicable

Ears/Nose/Throat *

Hearing loss or ringing

Earaches or drainage

Chronic sinus problem

Nose bleeds

Mouth sore

Sore throat or voice changes

Swollen glands in neck

Not applicable

Check 'not applicable' if no issues listed

Eyes *

Eye disease or injury

Wear glasses/contact lenses

Blurred or double vision

Glaucoma/cataracts

Not applicable

Check 'not applicable' if no issues listed

Cardiovascular *

Heart trouble

Chest pain or angina pectoris

Palpitation

Shortness of breath with walking or lying flat

Swelling of feet, ankles or hands

Not applicable

Check 'not applicable' if no issues listed

Respiratory *

Chronic or frequent coughs

Spitting up blood

Shortness of breath

Asthma or wheezing

Not Applicable

Check 'not applicable' if no issues listed

Psychiatric *

Memory loss or confusion

Nervousness

Depression

Insomnia

Not Applicable

Check 'not applicable' if no issues listed

Gastrointestinal *

Loss of appetite

Change of bowel movements

Nausea or vomiting

Frequent diarrhea

Painful bowel movements/constipation

Rectal bleeding or blood in stool

Abdominal pain

Peptic ulcer (stomach or duodenal)

Not applicable

Check 'not applicable' if no issues listed

Musculoskeletal *

Joint pain

Joint stiffness or swelling

Weakness of muscles or joints

Muscle pain or cramps

Back pain

Difficulty in walking

Not applicable

Check 'not applicable' if no issues listed

Genitourinary *

Check 'not applicable' if no issues listed

Integumentary (skin,breast)

Rash or itching

Change in skin color

Change in nail color

Varicose veins

Breast pain

Breast lump

Breast discharge

Not applicable

Check 'not applicable' if no issues listed

Neurological *

Frequent or recurring headaches

Light headed or dizzy

Convulsions or seizures

Numbness or tingling sensations

Shakes

Paralysis

Stroke

Head injury

Not Applicable

Check 'not applicable' if no issues listed

Endocrine

Glandular or hormone problem

Thyroid disease

Diabetes (insulin)

Diabetes (non-insulin)

Excessive thirst or urination

Heat or cold intolerance

Not applicable

Check 'not applicable' if no issues listed

Allergic/ Immunologic - History of skin or adverse reaction to? *

Penicillin or other antibiotics

Morphine, Demerol or other narcotics

Novocain or other anesthetics

Aspirin or other pain remedies

Tetanus or other serums

Iodine, Merthiolate or other antiseptic

Other drugs/medications:

Not applicable

Check 'not applicable' if no issues listed

Any other drugs or medications allergic to?

Thank you, please submit

F Parker Thornton MD LLC

Available Forms

NEW Patient - Health History Form (PMH)