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New Patient Questionaire
 
Address:
State:     Zip Code:
Phone:
Email:
Language Preference:
 If other explain:
Mode of Transportation:                                               
Name of physician involved in care Would you like them to receive copies of our recommendation?
    
    
    
    
    
 
 
Describe briefly how your illness started, how it was diagnosed and what has happened up until now:
 
Reason for Consultation
When were you diagnosed?    
Date Picker
 
Treatment you’ve received: yes / no: What Hospital: Describe:
Surgery
Radiation
Drug Tx / Chemo
Blood Transfusion
Blood Support (Neupogen, etc.)
Hormone Therapy
 
Scans, X-Rays, or other tests related to your diagnosis
Test: yes / no: Performed Where?: Date:
CT Scan
Date Picker
MRI Scan
Date Picker
Bone Scan
Date Picker
Ultrasound
Date Picker
Pet Scan
Date Picker
Other
Date Picker
 
Past Medical History
Have you had radiation before?
  
 
Have you had any cancers?     If yes, list below.
  Date Diagnosed: Type of Cancer: Treatment Received:
 
Date Picker
 
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Present Medical History
Do you have any ongoing of the following medical conditions:
Test: yes / no: If yes, describe:
High blood pressure
Heart disease
High cholesterol
Heart attack
Cardiac arrhythmia
Blood clots (lung, leg, etc)
Emphysema, asthma, COPD
Kidney disease
Stomach disease (ulcers, reflux)
Bowel disease
(inflammatory bowel disease, colitis, Crohn’s, etc)
Diabetes (type I, type II)
Thyroid problems
Lupus
Scleroderma
ALS
Other
Other
 
Past Surgical History
Have you had any other procedures or operations?    Select one:     If yes, please list below:
  Date of surgery: Type of surgery: Hospital where performed:
 
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Do you have an Internal Electronic Device, i.e. defibrillator, pacemaker?    
If yes, please have your card ready at the time of consultation for the nurse and doctor.
 
Allergies (medication, food, latex, etc)?         If yes, please describe below:
  Allergy to: Describe reaction:
 
 
 
 
 
 
List all prescribed medication that you are currently taking
Drug: Dose: How Often: Prescribed by: Why:
 
List any over-the-counter medications you are currently taking    (Tylenol, Advil, Antacids, Vitamins, etc)
Drug: Dose: How Often: Prescribed by: Why:
 
Social History
Marital status: (select one)
Do you drink alcohol?
  If yes,    select all that apply:
Number of drinks per week:
If you used to drink, when did you stop?  
Date Picker
Do you smoke?
  If yes,    packs per day for years
What type of work do / did you do?
Are you retired?   If yes, when?
Date Picker
Do you live alone?
  If no, with whom do you live?
Do you have children?
  If yes, list ages:
Do you use recreational drugs? (Marijuana, cocaine, etc.)
  If Yes, which drugs?
 
Family History
Do / did any family members suffer from cancer or blood disease?
If yes, please describe below:
Family member Type of cancer / blood disease Age at diagnosis
 
Women:
Do you have regular mammograms?     Last Exam:
Date Picker
Do you have regular PAP test?     Last Exam:
Date Picker
Do you have regular breast exams?     Last Exam:
Date Picker
Do you examine your own breasts?     Last Exam:
Date Picker
 
Female History    (N/A to Male Patients)
Date of last menstrual period:  
Date Picker
Age that you started menstruating:
Age at menopause:
Have you had a hysterectomy?
  If yes, were your ovaries removed?
Do / did you use oral contraceptives?
  If yes, how many years?
Do / did you use hormone replacement therapy?
  If yes, how many years?
Number of pregnancies:
         Number of live births:
 
Men:
Do you have regular prostate exams?     Last Exam:
Date Picker
Do you have regular PSA tests?     Last Exam:
Date Picker
Do you examine your own testicles?     Last Exam:
Date Picker
 
Health Maintenance:
Have you had a flu vaccine?     When?
Date Picker
Have you had a pneumonia vaccination?     When?
Date Picker
Have you had a sigmoidoscopy / colonoscopy?     When?
Date Picker
Has your doctor checked your stool for blood?     When?
Date Picker
 
Advance Directives
Do you have a living will?
Do you have a Durable Power of Attorney for Health Care?
If yes to either of the above, will you have the documents with you?
If unavailable:
Name of Agent:
           Phone number:
Essence of Advance Directive in patient / family words:
If no, would you like assistance obtaining this information?                
 
Contact Information
Name of closest relative:
Address:
Home phone:
 
Emergency contact person:
Relationship:
Address:
Home phone:
 
Review of Systems    (Select appropriate response)
General:
Fever, fatigue, night sweats, chills, hot flashes
  If yes, explain:
Difficulty sleeping, changes in appetite
  If yes, explain:
Weight loss / gain?
   If yes, how many pounds in which direction?
Describe your activity level:
 
Skin:
Rash, moles or changes in
moles, sores, lumps, dryness, itching?
If yes, explain:
Healing incision, vascular access (port a cath, pic line)
If yes, explain:
If yes, last date flushed:  
Date Picker
 
Eyes, Ears, Nose, Throat:
Wear hearing aid(s)
If yes,     select one:
Dentures
If yes,     select one:
Blurred vision, double vision, red / water eyes, blind
If yes, explain:
Glaucoma
If yes, explain:
Corrected vision (glasses / contacts)
If yes, explain:
Cataracts / Surgery
If yes, explain:
Macular degeneration
If yes, explain:
Hard of hearing, ringing in the ears, ear pain
If yes, explain:
Frequent sinus infections, sore throat, hoarseness, mouth pain
If yes, explain:
Change in taste, smell, difficulty swallowing
If yes, explain:
 
Respiratory:
Shortness of breath
   If yes,   select one:
Cold, sore throat or fever in the last 2 weeks
   If yes, explain:
COPD, bronchitis, asthma, emphysema
   If yes, explain:
Hospitalized / in ER in the last 6 weeks     (respiratory related)
   If yes, explain:
Pneumonia, hemoptysis     (cough up blood)
   If yes, explain:
Able to walk two flights of stairs
   If NO, explain:
Sleep disorders, sleep apnea
   If yes, explain:
Pulmonary embolism
   If yes, explain:
Home oxygen?
   If yes, how many liters / min:
 
Cardiovascular:
Rheumatic heart disease
   If yes, explain:
Heart murmur, valvular disease
   If yes, explain:
Angina, chest pain
   If yes, explain:
MI (heart attack) Angioplasty, bypass, graft
   If yes, explain:
Arrhythmia, palpitations, atrial fib, SVT
   If yes, explain:
High blood pressure
   If yes, explain:
Pacemaker, defibrillator
   If yes, explain:
Blood clots in legs
   If yes, explain:
PVD     (peripheral vascular disease)
   If yes, explain:
Congestive heart failure, dizziness, fainting
   If yes, explain:
Abdominal aortic aneurysm
   If yes, explain:
 
Genitourinary:
Frequent urinary tract infections
   If yes, explain:
Blood in urine, kidney stones
   If yes, explain:
Pain, frequency, difficulty with flow, incontinence
   If yes, explain:
Prostate disease
   If yes, explain:
Renal insufficiency
   If yes, explain:
Chronic renal failure, new onset renal failure
   If yes, explain:
Failure, dialysis     (peritoneal / hemo)
   If yes, explain:
 
Gastrointestinal:
GI bleeding, stomach ulcer,
reflux (GERD), heartburn, hiatal hernia
   If yes, explain:
Chronic / acute hepatitis B / C / D / G
   If yes, explain:
Cirrhosis, jaundice
   If yes, explain:
Constipation, diarrhea, blood in stool
   If yes, explain:
Irritable bowel syndrome, colitis, Crohns disease
   If yes, explain:
Difficulty swallowing/chewing
   If yes, explain:
 
Muscoskeletal:
Weakness in extremities
    If yes, where:
Bone pain (not arthritis)
    If yes, where:
Limited movement
   If yes, explain:
Prosthesis, metal in joints, artificial joints
   If yes, explain:
Joint pain, joint swelling, fibromyalgia, arthritis
   If yes, explain:
Chronic back pain, back injury, neck injury
   If yes, explain:
Difficulty opening your mouth
   If yes, explain:
Spinal pain, spinal stenosis, cervical fusion
   If yes, explain:
 
Pain:
Chronic
   If yes, scale of 1-10 (1 being mild / 10 being severe):
New
   If yes, scale of 1-10 (1 being mild / 10 being severe):
 
Neurological:
Stroke, TIA, Parkinson’s, polio
   If yes, explain:
Paralysis, tremors, weakness
   If yes, explain:
Multiple Sclerosis
   If yes, explain:
Epilepsy, seizures, convulsions
   If yes, explain:
Brain aneurysm, head injury
   If yes, explain:
Neuro implants: BP shunt, epidural device
   If yes, explain:
Have you recently experienced:
Loss of speech, memory loss, forgetfulness, slurred speech, speech impairment,
changes in vision, numbness, tingling, headache?
   If yes, explain:
 
Endocrine / Metabolic:
Diabetes
   If yes, select:                   
Thyroid disease
   If yes, select:                        
Insulin pump
   If yes, explain:
Hypoglycemia
   If yes, explain:
 
Hematological / Lymphatic:
Blood transfusion, anemia
   If yes, explain:
Prolonged bleeding, excessive bruising
   If yes, explain:
Enlarged lymphnodes
   If yes, explain:
 
Immunologic:
Lupus
   If yes, explain:
Chronic fatigue syndrome
   If yes, explain:
AIDS / HIV
   If yes, explain:
Immunosuppression
   If yes, explain:
 
Infectious Disease:
Recent exposure to an infectious disease
   If yes, explain:
Tuberculosis
   If yes, explain:
In isolation
   If yes:    Type:

  Date:
Date Picker
 
Psychosocial / Behavioral:
Currently experiencing stress in your life?
   (1=mild, 10=high):                                                    
Currently have concerns regarding
sleep patterns, appetite, eating habits, energy level
   If yes, explain:
Panic disorder, depression, bipolar, anxiety
   If yes, explain:
Religious, spiritual, or cultural needs
   If yes, explain:
Obsessive / compulsive, schizophrenia
   If yes, explain:
 
Nutritional:
Diet (General, diabetic, cardiac, etc.)
   If yes, explain:
Food Allergies
   If yes, explain:
On a supplement
   If yes, explain:
Recent surgery (less than 2 months)
   If yes, explain:
Poor oral intake (less than 50% for 3 days)
   If yes, explain:
Difficulty chewing / swallowing
   If yes, explain:
 
 
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