New Patient
Medical History

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Patient Name

Today's Date

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Date of Birth

Sex

Age

How did you hear about our practice?

Please briefly state in the box below the reason for Your visit

Past Medical History

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Condition / Disease

Year Began

Other Medical Conditions

Year Began

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Hypertension

Hypertension

Hypertension Year Began

Name Other Medical History

Other Year Began

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High Cholesterol

High Cholesterol

High Cholesterol Year Began

Name Other Medical History

Other Year Began

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Hypothyroidism (low thyroid)

Hypothyroidism (low thyroid)

Hypothyroidism (low thyroid) Year Began

Name Other Medical History

Other Year Began

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COPD, Emphysema or Asthma

COPD, Emphysema or Asthma

COPD, Emphysema or Asthma Year Began

Name Other Medical History

Other Year Began

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Diabetes

Diabetes

Diabetes Year Began

Other Medical History

Other Year Began

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GERD

GERD

Gerd Year Began

Other Medical History

Other Year Began

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Depression or Anxiety

Depression or Anxiety

Depression or Anxiety Year Began

Other Medical History

Other Year Began

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Heart Problems

Heart Problems

Heart Problems Year Began

Other Medical History

Other Year Began

Past Surgical Procedures / Hospitalizations / Serious Injuries or Fractures

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Operation / Hospitalization / Injury

Month/ Yr.

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Operation / Hospitalization / Injury

Month / Yr.

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Operation / Hospitalization / Injury 2

Month / Yr.

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Operation / Hospitalization / Injury 3

Month / Yr.

Medication or Food Allergies or Intolerances

List below medications or foods causing an allergic reaction (i.e., rash, swelling) or intolerance (i.e., nausea)

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Medication / Food

Reaction

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Medication / Food

Reaction

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Medication / Food

Reaction

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Medication / Food

Reaction

Medications, Vitamins and Herbal Supplements

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Local Pharmacy Name

Pharmacy Phone #

Location

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Medication

Example: Tylenol

Strength

500ml

Number of Pills taken & frequency

1 - twice daily

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Medication

Strength

Number of Pills taken & frequency

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Medication (copy)

Strength (copy)

Number of Pills taken & frequency (copy)

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Medication (copy) (copy)

Strength (copy) (copy)

Number of Pills taken & frequency (copy) (copy)

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New Patient Medical History

Past Medical History

Past Surgical Procedures / Hospitalizations / Serious Injuries or Fractures

Medication or Food Allergies or Intolerances

Medications, Vitamins and Herbal Supplements

New Patient
Medical History