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Free Colorful Table Format New Patient Questionnaire

The FREE colorful table format New Patient Questionnaire is a comprehensive medical history form designed to be filled out by the health care consumer prior to a visit with a health care provider.   This MedicalTemplate is appropriate for a new patient evaluation or any visit to a health care provider.

New Patient Form - Upload a Document to Scribd Read this document on Scribd: New Patient Form Health Care Consumer Questionnaire Patient Patient Name DOB Patient Address Gender ‰Female ‰Male Phone H W C Phone DOB Date SSN Emergency Contact Date Primary Insurance Secondary Insurance Phone H W C Phone Policy # Policy # List ALL Health Care Providers from whom you are currently receiving care (or have seen within the past 12 months), AND ALL Health Care Providers from whom you are obtaining prescriptions. Health Care Provider Phone Health Care Provider Phone Have you completed Advance Health Care Directives? ‰Yes ‰No (Living Will or Durable Power of Attorney for Healthcare) Please provide a copy as soon as possible If yes, please provide the name and contact information for your Health Care Power of Attorney If No, whom would you prefer as a surrogate decision maker should you need one? Do you have any religious or cultural beliefs that may affect your healthcare? If yes, explain Describe the means by which you prefer to learn new information ‰Verbal Instruction ‰Written Instruction ‰Handouts ‰Visual (Pictures, Videos, etc) Language you prefer to converse in Level of education completed ‰<6th grade ‰6th – 8th grade ‰9th grade ‰12th grade ‰1-4 years college ‰>4 years college If the person completing this form is not the patient, please write your full name, relationship to the patient, and the specific reasons that the patient is unable to complete this form. ” MB & RR 2008 e-medtools.com ‰The information on this page was reviewed with the patient HCC Initials _____ HCP Initials _____ 1 Health Care Consumer Questionnaire Patient Allergies Please describe reactions DOB Date ‰Shellfish ‰IV Contrast ‰Penicillins ‰Other, specify Please list medications you are taking. Medication & Dose Include ALL over the counter medications, herbs & vitamins. Frequency Medication & Dose Frequency Have you ever been exposed to known cancer-causing agents or inhalation hazards? ‰Yes ‰No If yes, please list the agents as specifically as possible, and state the duration of exposure as best as possible. Agent Duration Agent Duration Please list and describe your hobbies Have you traveled in the past 12 months? ‰Yes ‰No Within the United States Duration If yes, please list locations and time spent traveling. Outside the United States Duration Do you exercise? ‰Yes ‰No Activity & Duration If yes, please describe activities, frequency and duration of each activity Times/Week Activity & Duration Times/Week ” MB & RR 2008 e-medtools.com ‰The information on this page was reviewed with the patient HCC Initials _____ HCP Initials _____ 2 Health Care Consumer Questionnaire Patient Substance Use and Personal Risk History Have you ever smoked tobacco as cigarettes, cigars or pipes? Have you quit? If yes, when Have you ever chewed tobacco? Have you quit? If yes, when Have you considered quitting? Have you tried quitting? If yes, for how long did you quit? Do you drink alcohol? DOB Date #Packs #Pouches ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰No ‰No ‰No ‰No ‰No ‰No #Years #Years #Drinks ‰Day ‰Week ‰Yes ‰No 1 “drink” is equal to 12 oz. beer,1.5 oz. 80-proof liquor, or 5 oz. glass of wine Have you ever lost consciousness as a result of drinking alcohol? Have you ever had a “drink” to prevent tremors, sweats, or irritability? Have you ever been ticketed or arrested for a DUI? Have you been involved in a motor vehicle accident in the past 12 months? Have you ever used drugs for recreational purposes? ‰Yes ‰Yes ‰Yes ‰Yes ‰No ‰No ‰No ‰No Check all that apply ‰Yes ‰No ‰Amphetamines ‰Cocaine ‰Heroin ‰Inhalants ‰LSD ‰Marijuana ‰PCP ‰Other, specify Method of drug delivery you used ‰Ingestion ‰Injection ‰Inhalation How much of each drug would you use? List drugs below Amount Frequency ‰Day ‰Week ‰Day ‰Week ‰Day ‰Week Check all that apply Have you ever been dependent on prescription drugs? ‰Yes ‰No ‰Narcotics ‰Benzodiazepines Specify If Other Are you sexually active? ‰Yes ‰No If yes, do you use contraception of any kind? Check all that apply ‰Condoms ‰Diaphragm ‰Intrauterine Device IUD ‰Pills, Implants, Patches How many sexual partners have you had in the past 12 months? Do you feel safe in your relationship? Have you ever been in a relationship where you were threatened, hurt or afraid? Do you have a safe place to go, and do you have the resources to leave, if you feel threatened? # Have you ever had sex with a person who is the same gender as yourself, bisexual, or anyone who performs sexual favors in exchange for money or drugs? Have you ever been diagnosed with a sexually transmitted disease (such as syphilis, HIV, herpes, gonorrhea, chlamydia or genital warts)? ‰Yes ‰Yes ‰Yes ‰Yes ‰No ‰No ‰No ‰No ‰Yes ‰No ‰Yes ‰No ‰Yes ‰No Do you have any tattoos or body piercings? Have you ever received transfusions of blood or blood products? Describe your seatbelt use whether you are driving or are a passenger in a vehicle. ‰All the time ‰Most of the time ‰About half the time ‰Rarely ‰Never Do you keep firearms in your residence? If yes, are they kept in locked compartments, or do they have safety locks on when not in use? ‰Yes ‰No ‰Yes ‰No ‰Yes ‰No Can you perform your own hygiene, dressing, cooking and shopping needs? ” MB & RR 2008 e-medtools.com ‰The information on this page was reviewed with the patient HCC Initials _____ HCP Initials _____ 3 Health Care Consumer Questionnaire Patient DOB Date Prior Diagnostic Exam History Have you ever had the following exams? If so, list where and when. Exam Location and Month/Year PAP Smear ‰Yes ‰No Prostate Biopsy ‰Yes ‰No Mammogram ‰Yes ‰No Colonoscopy ‰Yes ‰No EGD (Esophageal endoscopy) ‰Yes ‰No EKG ‰Yes ‰No Cardiac Stress Test ‰Yes ‰No ECHO (Echocardiogram) ‰Yes ‰No Chest X-ray ‰Yes ‰No CT “Cat” Scan of Chest ‰Yes ‰No Pulmonary Function Test ‰Yes ‰No EEG (Electroencephalography) ‰Yes ‰No Bone Density Test ‰Yes ‰No Vaccinations Have you had any of the following vaccines? Check all that apply, and state date last received. Vaccine Date Received Influenza ‰Yes ‰No Pneumonia ‰Yes ‰No Tetanus ‰Yes ‰No BCG ‰Yes ‰No Varicella ‰Yes ‰No Human Papilloma Virus (Gardasil) ‰Yes ‰No Gynecologic History This section to be completed by females. Males should skip to next section. #Live births #Miscarriages or Abortions Have you ever been pregnant? ‰Yes ‰No How old were you when you started menstruating? How old were you when you started menopause? Have you ever used birth control pills, patches or implants? ‰Yes ‰No If yes, when Have you ever taken hormone replacement therapy? ‰Yes ‰No If yes, when Have you ever had an intrauterine (IUD) device? ‰Yes ‰No If yes, when If you had an IUD placed, was it removed? ‰Yes ‰No If yes, when Have you had a tubal ligation? ‰Yes ‰No If yes, when Have you had your ovaries surgically removed? ‰Yes ‰No If yes, when Surgical History Please list all surgical procedures you have had. Include physician’s name, and date of procedure. Surgical Procedure Physician Date ” MB & RR 2008 e-medtools.com ‰The information on this page was reviewed with the patient HCC Initials _____ HCP Initials _____ 4 Health Care Consumer Questionnaire Patient Past Medical History Check “yes” or “no” for each problem listed. Adrenal Dysfunction Alzheimer Amyotrophic Lateral Sclerosis Anorexia or Bulimia Anxiety Disorder Arteriovenous Malformations (AVMs) Arthritis Asthma Autoimmune Disease Bipolar Disorder Bleeding Disorder Cataracts Cerebrovascular Accident (Stroke) Chemotherapy If yes, state when Claudication Clotting Disorder Congenital Heart Defects Coronary Artery Disease COPD Cystic Fibrosis Depression Diabetes Dialysis Eclampsia or Pre-eclampsia Endocarditis Endometriosis End Stage Renal Disease Erectile Dysfunction Esophageal Dysfunction Fibromyalgia Gallstones Gastritis or Gastric Ulcers GERD (reflux problems) Glaucoma Heart or Valve Defects Hemochromatosis Hemorrhoids Hepatitis HIV or AIDS Hypertension Hyperthyroidism Hypotension Hypothyroidism Inflammatory Bowel Disease DOB Irregular Heart Rhythm Kyphosis Liver Dysfunction Kidney Failure, or Dysfunction Malignancy If yes, describe below Date ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No 5 Mania Muscular Dystrophy Myocardial Infarction (Heart Attack) Narcolepsy Obstructive Sleep Apnea Organ Transplant If yes, describe Osteoporosis Pancreatitis Periodic Limb Movement Disorder Peripheral Artery Disease Personality Disorder Pituitary Dysfunction Polycystic Ovarian Syndrome Pulmonary Artery Hypertension Pulmonary fibrosis Radiation Therapy If yes, explain Recurrent Infections Restless Leg Syndrome Sarcoidosis Schizophrenia Scleroderma Scoliosis Seizure Disorder Sickle Cell Sjogren Skin Disorders (Psoriasis, Acne) Thalassemia Thrombocytopenia Thrombophilia Transfusions Tuberculosis If yes, have you been treated? Urinary retention or urgency Vasculitis Visual defects Vocal cord dysfunction/paralysis ” MB & RR 2008 e-medtools.com ‰The information on this page was reviewed with the patient HCC Initials _____ HCP Initials _____ Health Care Consumer Questionnaire Patient Review of Systems Constitutional Weight Loss or Gain Appetite changes (increased or decreased) Fatigue, profound and impairs daily function Fever Shakes/sweats from lack of alcohol or drug DOB Date In the last 6 months have you experienced the following symptoms. Check either “yes” or “no” for each symptom. ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰No ‰No ‰No ‰No ‰No Genitourinary Blood in your urine Menstrual changes Urinating that is painful or difficult Erection problems Vaginal discharge or bleeding ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No Eyes Eye pain or drainage Visual changes Dry, irritated eyes ‰Yes ‰No ‰Yes ‰No ‰Yes ‰No ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No Musculoskeletal Broken bones Joint pain or swelling Muscle aches Muscle weakness Back pain ENT/Mouth Ear pain or drainage Frequent sinus infections Hearing changes or loss Nosebleeds Dizziness Skin/Breasts Masses or lumps Nipple discharge Rashes or nonhealing ulcers ‰Yes ‰No ‰Yes ‰No ‰Yes ‰No ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰Yes ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No ‰No Respiratory Blood in your sputum Chest tightness Cough lasting >1 month, productive or not Shortness of breath Wheezing Chest pain with inhalation or coughing Neurologic Seizures Coughing or choking with swallowing Excessive daytime sleepiness Extremity pain or burning sensations Hallucinations Numbness or tingling Difficulty falling asleep, staying asleep Cardiovascular Chest pain or heaviness Palpitations Fainting or near fainting spells Swelling of feet or legs Shortness of breath lying flat in bed Endocrinologic Hair loss Frequent urination Increased thirst Heat or cold intolerance Gastrointestinal Abdominal pain Blood in your stool Constipation Diarrhea or Food Intolerance Heartburn or Indigestion Vomiting or nausea lasting for >1 day Swallowing difficulty Heme/Lymph Bleeding from gums or nose Unexplained bruising Night Sweats Swollen, painful lymph nodes Psych Anxiety without clear explanation Sadness lasting for days or weeks Hearing voices Thoughts of hurting yourself Thought of hurting others Fear of people, places or things Allergy/Immun Watery eyes Runny nose Food intolerance Frequent skin sores ” MB & RR 2008 e-medtools.com ‰The information on this page was reviewed with the patient HCC Initials _____ HCP Initials _____ 6 Health Care Consumer Questionnaire Patient Family Medical History Please list all known medical problems in your family. Medical Problem Relative Medical Problem DOB Date (Specify M=Mother, F=Father, B=Brother, S=Sister, So=Son, D=Daughter, GM=Grandmother, GF=Grandfather) Relative Additional Information that you feel may be helpful for your health care provider to know. Health Care Provider Notes Referral Information – We would appreciate learning how you heard about us? Check one, please ‰Another physician, nurse practitioner or physician assistant? ‰Family member or friend who is a patient of this clinic ‰Family member or friend who is NOT a patient of this clinic ‰Sign outside your office ‰Billboard Ad ‰Media Ad Please specify ‰Television ‰Radio ‰Newspaper Ad ‰Hospital referral service ‰Phone book ‰Internet ‰Other, please specify If so, please specify who: ” MB & RR 2008 e-medtools.com ‰The information on this page was reviewed with the patient HCC Initials _____ HCP Initials _____ 7 Template updated 2/20/2008

The Health Care Consumer Questionnaire is a detailed 8-page snapshot of an individual’s current and past medical problems. 

Information included in the colorful table format Health Care Consumer Questionnaire

• Allergies
• Medications
• Surgeries
• Past Medical History
• Family Medical History
• Review of systems
• Social History
• Religious and cultural beliefs
• Travel history
• Occupational history
• Carcinogen exposure history
• Behavioral risk factors

MedicalTemplates are in the Adobe PDF format, which requires the free Adobe Reader.  With Adobe Reader, these templates can be printed as many times as needed on paper meeting your specifications or the specifications of any clinic, hospital, or other health care facility.