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- Spring 2018 -

Ticks and Lyme Disease Including Chronic Lyme Disease

Lyme Disease NIH INfo 2012

Your Guide to Lowering Blood Pressure with the DASH Diet

Heart Disease A Visual Slideshow

About Chronic Kidney Disease

Chronic Kidney Disease

Chronic Kidney Disease and The Family Doctor

Vitamin D Info

Daily aspirin therapy: Understand the benefits and risk Mayo Clinic

Help Managing Your Diabetes

Diabetes Center Mayo Clinic Link

Lantus SoloStar Pen Picture

Treatment of Upper Respiratory and Sinus Infections

Insulin Injection

Smoking Cessation Center WebMD

Seasonal & Food and Other Allergies

Fish Oil Supplements

Vitamin D Deficiency

Colonoscopy Explained

No Increase in Cancer with ARBs

FDA & Dietary Supplements

Flu Treatment from WebMD

Common Cold from Mayo Clinic

Neck & Back Pain Videos

Smoking Cessation Resources

more...
» Healthtrax «

Physician-Referred Exercise Program
New Patient FormFollow Up Visit
WebMD Health Headlines
WHO Calls ‘Gaming Disorder’ Mental Health Condition
Why Obese People Find It So Tough to Slim Down
When the Heart Stops, Drugs Often to Blame
What Is a 'Good Death'?
How Much Drinking Is Healthy -- or Not?
Marriage Is Good Medicine for the Heart
Severe Stress May Send Immune System Into Overdrive
People With Diabetes Forgo Medical Care Due to Costs
Single Blood Test Might Diagnose Diabetes
U.S. Smoking Rate Hits All-Time Low
Disney's 'Incredibles 2' Could Pose Epilepsy Risk
Congress May Soon Make CBD From Hemp Legal

New Patient Form

Please complete prior to your first visit to the office. If you would prefer to print this form, please use the printable New Patient Form. Remember to bring your co-pay at the time of the visit (Insurance requirement).

Patient Information


* Required
* Name:
* Address:
* City:
* State:    * Zip Code:
* Home Phone:
Work Phone:
Cell Phone:
* Date of Birth:
Social Security Number: --
Marital Status:
Name of Nearest Relative:
Incl. Spouse, Sig. Other

Relationship:

Insurance Information


Insurance Plan:
Insurance Number:
Insurance Group:
Co-Pay Amount:
(provide prior to visit)
$

Employment Information


Place of Employment:
Occupation:
Employers Workers Compensation Carrier (if applicable):
Please provide WC carrier Name, Address and Phone

Referral Information


Previous Physician:
Date Last Seen:
Referred To This Office by:
(Relative, Friend)

Reason For Visit


State the reason(s) that you are here to see the doctor (eg. new patient exam, yearly, specific problem(s) to be addressed). Please try to describe what the problem(s) is/are, when the problem(s) began, how severe the problem(s) is/are, and all related symptoms that you may be having. Please state whether these are ongoing or new problems.

Medication Information


Current Medications
Allergies to Medication:
(Codiene, Penicillin, etc)
Please list medications and type of reaction (eg. Swelling, Rash, Breathing, etc.)
Health-Food or Over-the-Counter Products
Please list any health-food or over-the-counter products you are taking, or have taken recently (eg. Kava, DHEA, supplements, cough medicines, St. John's Wart, etc.)

Medical History


List any Significant Illnesses or Injuries in the Past Five Years
List any Surgeries in the Past Five Years
List any Hospitalizations in the Past Five Years
Have you been, or are you now under the care of a Specialist(s)? If so, please provide name(s).
(Including Orthopedic, Neurologist, Psychiatric, Chiropractic, Physical Therapy)
Will you require referrals in the near future? If so, please list.

Social History


Smoking History

Packs Per Day:
Number of Years:
Have You Quit?:   If Yes, what date:
Are you interested in quitting?:

Alcohol History

Alcohol Usage:
Type of Liquor:
Beer, Wine, Vodka, Whiskey, etc.

Other Lifestyle Information

Caffeine Intake:
Including Soda, Tea
Illicit Drug or Stimulant Use in the Past Five Years:
Diet:
Please Explain:
History of eating disorder:
(eg Anorexia or Bulemia)
Please Explain:
Amount of Exercise:
Type of Exercise:
(Walking, Aerobics)
Do you wear seatbelts?:
Do you use sunscreen?:

Sexual History


Do you have a history, or have you been in contact with, someone having any the following?:

AIDS/HIV
Chlamydia
Trichomonas
Condyloma
Gonorrhea
Syphilis
Pelvic Inflammatory Disease
Other

Please Explain your illness and treatment:
Do you have, or have you had, more than 3 sexual partners?

Family Health History


Father Father Alive?
Age at Death 
Cause of Death 
Mother Mother Alive?
Age at Death 
Cause of Death 
Brother Brother Alive?
Age at Death
Cause of Death
Sister Sister Alive?
Age at Death
Cause of Death
 

Significant Family Illnesses

List any family history of cancer, diabetes, high blood pressure, heart disease, stroke, alcoholism, bleeding disorder, liver disease, kidney disease, other illness or disease.

Family Psychological History

Is there any family history of bipolar disorder, manic depression, schizophrenia, severe depression, chronic anxious state, or chronic treatment with anti-depressant, anti-anxiety or other medication?

Your Medical History


Symtoms or Illnesses over the past 1-2 years

Please check all that apply
General
Increased Thirst
Increased Urination
Increased Hunger
Insomnia
Night Sweats
Tiredness
Unusual Bruising
Weakness
Weight Gain
Weight Loss

Skin
Easy bleeding
Changes in moles or birthmarks
Changes in skin
History of cellulitis or lymphangitis (blood poisoning)
History of eczema or dermatitis
Increased sweating
Itching
Loss of hair
Skin discoloration
Slow healing areas of skin
Sores or other lesions
Varicose veins of the lower extremities

Head
Headaches accompanied by visual changes, dizziness, etc
Cataract or glaucoma history
Dizziness
Ear pain or discharge
Hearing loss
Loss of taste and smell
Poor or blurred vision
Sneezing or itchy eyes
Unusual headaches
Visual loss

Lymphatic (Glandular)
Breast lumps or masses
Swollen glands in the neck, axilla, or elsewhere

Genitourinary
Changes or lack of menstrual period
Discharge from penis or vagina
Frequent or changing urination
History of kidney stones
History of uterine fibroids of ovarian cysts
Incontinence of urine with cough or laughing or sneezing
Itching or burning on urination
Loss of bladder control
Pain on urination
Pain with intercourse
Problems with erection
Sores on the penis
Sores on the vagina

Nervous System
Convulsions or seizure history
Head injuries
Loss of sensation (hands, feet, face)
Memory changes or loss
Migraine or headache history
Visual problems

Psychological
History of anxiety or nervousness
History of depression
History of feeling sad or blue
History of panic episodes
Personality changes
Suicide thoughts, ideas or plans?
Respiratory
Allergy conditions
Chronic cough
Coughing up blood
History of asthma
History of exposure to asbestosis
History of smoking
Other noises in the chest
Problems breathing out of the nose
Shortness of breath at rest
Shortness of breath lying down
Shortness of breath with activity
Wheezing

Heart
Arm pains
Calf pains or swelling
Chest pains at rest
Chest pains with activity
Fainting episodes
Heart murmurs
History of stroke or CVA
Jaw pains
Leg pains
Palpitations (extra heartbeats)
Pressure in the chest
Shortness of breath when lying flat on the back

Gastrointestinal
Blood in the stool (or on toilet paper)
Changes in color or size of bowel movements
Changes in stool
Decreased appetite belching
Difficulty in swallowing
Frequent use of laxatives or antacids
Gallstones
Heartburn
Hemorrhoids (piles)
History of colitis
History of constipation (describe)
History of diarrhea (describe)
Increased appetite
Indigestion
Nausea and/or Vomiting
Stomach cramps or Stomach pain

Musculoskeletal
Ankle injuries
Coldness of extremities
Edema of extremities
Headaches
History of concussion
History of muscle strains or contusions
Low back pain
Motor Vehicle Accidents
Numbness in extremities
Pain in the ankles or feet
Pain in the fingers or wrists
Pain in the hips or knees
Pain in the shoulders or injury to the shoulders
Pain in the upper back
Severe lacerations or injuries
Sports related injuries
Swelling of the ankles or feet
Trauma to the head
Treatment or physical therapy
Treatment rehabilitation
Treatments by orthopedic, neurologists,etc
Work-related injuries (Please explain below)
Please explain the checked items above. Please add any symptoms that are not listed above.

For Women Only


Who is your Obstetrician-Gynecologist:
Including Nurse Practitioner or mid-wife
Date of last pelvic exam/pap smear:
Date of last mammogram:
List abnormal pap smears:
List abnormal mammograms:
List treatments for above:
Monthy Breast Exam?
Number of times pregnant:
Number of Children
Ages of Children
Pregnancy Terminations
Reason for Terminations

Hormonal History

Are you taking estrogens, estrogen/progesterone combination, Evista, Miacalcin, patch or other medication? If so, please list:

Menstrual History

Last Mentrual Period
Type of Birth Control
Name of Pill (if applicable)
Menstrual Periods
Days in cycle
(22, 27, 30 etc)
Length of menses
(days 2, 3, 5 or 7)
Age at onset of menses
(11, 13, 15 etc)
Any irregular bleeding, spotting, pain etc.?
Premenstrual Symptoms
(bloating, headache, etc)
Postmenopausal?   If No, months since last menstrual period:

Surgical History

eg Hysterectomy (removal of uterus only); Ovaries only removed; Total Hysterectomy (Uterus + Ovaries), or Tubal litigation ("tubes tied")
Age at time of surgery
Reason for surgery
Other Surgeries
Urinary symptoms, lack of control, incontinence, inability to urinate, etc?

Questions or Problems


Do you have any question or problems that you would like the doctor to focus on during your visit?