NEW PATIENT HISTORY
e.g. John B. Smith
day/month/year
Please describe the problem(s) for which you are seeking help.
Mark the test(s) you had for your present problem.
What drugs / treatments have you tried for your problem(s)? Did they help? Did you have a reaction?
Medical History
List your present and past MEDICAL problems and surgeries. Example: High blood pressure, diabetes, heart attack, hypothyroidism, hernia repair...
Number of packs of cigarettes or cigars you smoke per day.
What year did you start to smoke? Leave blank if not smoking.
Number of alcoholic drinks you drink a week.
What sort of alcohol do you drink?
Number of caffeinated drinks you drink a day?
Number of 8 ounces glasses of fluid do you drink in a day? Include all drinks, water, juices, soda, etc.
Have you been using any of this drugs?
Have you used any of the above drugs in the past?
Mark any problems that occurred in your close relatives, including grandparents, parents, siblings, children.
List any additional medical problems your close relatives had, including your parents, siblings, children, grandparents.
List of complaints: past or current symptoms
Please mark any condition that apply
Please mark any conditions that apply
Please mark any conditions that apply
Please mark any condtions that apply
Please mark any conditions that apply
Please mark any conditions that apply
Please mark any conditions that apply
Please mark any conditions that apply
Please mark any conditions that apply
Please mark any conditions that apply
Please mark any conditions that apply
Please mark any conditions that apply
Please mark any conditions that apply
Please mark any conditions that apply
List the names of physicians who should receive your report.
