New Patient Packet

Patient First Name

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Patient Last Name

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Date of Birth:

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Personal History of Past Iliness

Anemia

Yes

Please select an option.

If Yes, Date:

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Arthritis / Joint Pain

Yes

Please select an option.

If Yes, Date:

Please complete this field.

Asthma

Yes

Please select an option.

If Yes, Date:

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Back Problems

Yes

Please select an option.

If Yes, Date:

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Blood Clot in Lungs or Legs

Yes

Please select an option.

If Yes, Date:

Please complete this field.

Blood Transfusions

Yes

Please select an option.

If Yes, Date:

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Blood Clot in Lungs or Legs

Yes

Please select an option.

If Yes, Date:

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Bowel Problems

Yes

Please select an option.

If Yes, Date:

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Broken Bones

Yes

Please select an option.

If Yes, Date:

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Cancer

Yes

Please select an option.

If Yes, Date:

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Cataracts

Yes

Please select an option.

If Yes, Date:

Please complete this field.

Chickenpох

Yes

Please select an option.

If Yes, Date:

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Cataracts

Yes

Please select an option.

If Yes, Date:

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Collagen Vascular Disease (Lupus)

Yes

Please select an option.

If Yes, Date:

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Depression or Anxiety (circle)

Yes

Please select an option.

If Yes, Date:

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Diabetes

Yes

Please select an option.

If Yes, Date:

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Eating Disorders

Yes

Please select an option.

If Yes, Date:

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Gallbladder Disease

Yes

Please select an option.

If Yes, Date:

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Glaucoma

Yes

Please select an option.

If Yes, Date:

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Headaches (chronic only)

Yes

Please select an option.

If Yes, Date:

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Heart Disease

Yes

Please select an option.

If Yes, Date:

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Hepatitis/Yellow Jaundice/Liver Disease

Yes

Please select an option.

If Yes, Date:

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High Blood Pressure

Yes

Please select an option.

If Yes, Date:

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High Cholesterol

Yes

Please select an option.

If Yes, Date:

Please complete this field.

HIV/Aids

Yes

Please select an option.

If Yes, Date:

Please complete this field.

Kidney Infection/Kidney Stones

Yes

Please select an option.

If Yes, Date:

Please complete this field.

Pneumonia/Lung Disease

Yes

Please select an option.

If Yes, Date:

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Reflux/Hiatal Hernia/Ulcer

Yes

Please select an option.

If Yes, Date:

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Rheumatic Fever

Yes

Please select an option.

If Yes, Date:

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Seizures/Convulsions/Epilepsy

Yes

Please select an option.

If Yes, Date:

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Sexually Transmitted Disease

Yes

Please select an option.

If Yes, Date:

Please complete this field.

Stroke

Yes

Please select an option.

If Yes, Date:

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Thyroid Disease

Yes

Please select an option.

If Yes, Date:

Please complete this field.

Tuberculosis

Yes

Please select an option.

If Yes, Date:

Please complete this field.

GYN History

Abnormal Hair Growth

Yes

Please select an option.

Abnormal Bleeding

Yes

Please select an option.

Abnormal Pap Smear

Yes

Please select an option.

Breast Problems

Yes

Please select an option.

Cyst of Vulva

Yes

Please select an option.

DES Exposure

Yes

Please select an option.

Endometriosis

Yes

Please select an option.

Fibroid Uterus

Yes

Please select an option.

Infertility

Yes

Please select an option.

Ovarian Cyst

Yes

Please select an option.

Osteoporosis

Yes

Please select an option.

Sexual Problems

Yes

Please select an option.

Sexually Transmitted Disease

Yes

Please select an option.

Uterine Abnormality

Yes

Please select an option.

Urinary Leakage

Yes

Please select an option.

Vaginal/Vulvar Infection

Yes

Please select an option.

Surgeries

Abdominal Surgery

Yes

Please select an option.

Date / Comments

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C-Section Delivery

Yes

Please select an option.

Date / Comments

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Dilation & Curettage (D & C)

Yes

Please select an option.

Date / Comments

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Hysterectomy

Yes

Please select an option.

Date / Comments

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Hysteroscopy (out patient)

Yes

Please select an option.

Date / Comments

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Laparoscopy (out patient)

Yes

Please select an option.

Date / Comments

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Vaginal Surgery

Yes

Please select an option.

Date / Comments

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Vaginal Surgery

Yes

Please select an option.

Date / Comments

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Bartholin Glands Surgery

Yes

Please select an option.

Date / Comments

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Other (please specify)

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Social History

Preferred Name:

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PCP:

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Occupation:

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Number of People in Household:

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Education (last grade completed):

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Name of significant other:

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Children's Names:

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How many days per week do you exercise?

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How many packs of cigarettes per day do you smoke?

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How many times per week do you drink alcohol?

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Family History - Please check all that apply

Mother

Breast Cancer

Colon Cancer

Ovarian Cancer

Alzheimer's Disease

Birth Defects

Blood Clots in lungs or legs

Diabetes

Drinking or Drug Problem

Endometriosis

Fibroids

Heart Disease

Hepatitis

High Blood Pressure

High Cholesterol

HIV/AIDS

Mental Illness/Depression

Osteoporosis

Stroke

Tuberculosis

Other

Please complete this field.

Father

Breast Cancer

Colon Cancer

Ovarian Cancer

Alzheimer's Disease

Birth Defects

Blood Clots in lungs or legs

Diabetes

Drinking or Drug Problem

Endometriosis

Fibroids

Heart Disease

Hepatitis

High Blood Pressure

High Cholesterol

HIV/AIDS

Mental Illness/Depression

Osteoporosis

Stroke

Tuberculosis

Other

Please complete this field.

Sibling

Breast Cancer

Colon Cancer

Ovarian Cancer

Alzheimer's Disease

Birth Defects

Blood Clots in lungs or legs

Diabetes

Drinking or Drug Problem

Endometriosis

Fibroids

Heart Disease

Hepatitis

High Blood Pressure

High Cholesterol

HIV/AIDS

Mental Illness/Depression

Osteoporosis

Stroke

Tuberculosis

Other

Please complete this field.

Child

Breast Cancer

Colon Cancer

Ovarian Cancer

Alzheimer's Disease

Birth Defects

Blood Clots in lungs or legs

Diabetes

Drinking or Drug Problem

Endometriosis

Fibroids

Heart Disease

Hepatitis

High Blood Pressure

High Cholesterol

HIV/AIDS

Mental Illness/Depression

Osteoporosis

Stroke

Tuberculosis

Other

Please complete this field.

Maternal Grandmother

Breast Cancer

Colon Cancer

Ovarian Cancer

Alzheimer's Disease

Birth Defects

Blood Clots in lungs or legs

Diabetes

Drinking or Drug Problem

Endometriosis

Fibroids

Heart Disease

Hepatitis

High Blood Pressure

High Cholesterol

HIV/AIDS

Mental Illness/Depression

Osteoporosis

Stroke

Tuberculosis

Other

Please complete this field.

Maternal Grandfather

Breast Cancer

Colon Cancer

Ovarian Cancer

Alzheimer's Disease

Birth Defects

Blood Clots in lungs or legs

Diabetes

Drinking or Drug Problem

Endometriosis

Fibroids

Heart Disease

Hepatitis

High Blood Pressure

High Cholesterol

HIV/AIDS

Mental Illness/Depression

Osteoporosis

Stroke

Tuberculosis

Other

Please complete this field.

Paternal Grandmother

Breast Cancer

Colon Cancer

Ovarian Cancer

Alzheimer's Disease

Birth Defects

Blood Clots in lungs or legs

Diabetes

Drinking or Drug Problem

Endometriosis

Fibroids

Heart Disease

Hepatitis

High Blood Pressure

High Cholesterol

HIV/AIDS

Mental Illness/Depression

Osteoporosis

Stroke

Tuberculosis

Other

Please complete this field.

Paternal Grandfather

Breast Cancer

Colon Cancer

Ovarian Cancer

Alzheimer's Disease

Birth Defects

Blood Clots in lungs or legs

Diabetes

Drinking or Drug Problem

Endometriosis

Fibroids

Heart Disease

Hepatitis

High Blood Pressure

High Cholesterol

HIV/AIDS

Mental Illness/Depression

Osteoporosis

Stroke

Tuberculosis

Other

Please complete this field.

Other

(Who?)

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Breast Cancer

Colon Cancer

Ovarian Cancer

Alzheimer's Disease

Birth Defects

Blood Clots in lungs or legs

Diabetes

Drinking or Drug Problem

Endometriosis

Fibroids

Heart Disease

Hepatitis

High Blood Pressure

High Cholesterol

HIV/AIDS

Mental Illness/Depression

Osteoporosis

Stroke

Tuberculosis

Other

Please complete this field.

Obstetric History

#Total Pregnancies

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# Miscarriages

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# Full Term

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# Ectopic

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#Premature

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# Multiples

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# Elective Abortions

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# Living

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#Adopted

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Pregnancy Details # 1

Delivery Date

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Weeks at Delivery

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Length of Labor (hrs)

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Epidural/Anesthesia

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Did you have Pre-term Labor?

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Delivery Location?

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Who delivered your baby?

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Baby welght?

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Baby Sex?

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Baby Name?

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Complications of Pregnancy (Please check all that apply)

Gestational Diabetes

Macrosomia

Multiple Gestation

Post Dates

Postpartum hemorrhage

Pre-eclampsia

Preterm Delivery

Other Complication

Please complete this field.

Pregnancy Details # 2

Delivery Date

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Weeks at Delivery

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Length of Labor (hrs)

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Epidural/Anesthesia

Please complete this field.

Did you have Pre-term Labor?

Please complete this field.

Delivery Location?

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Who delivered your baby?

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Baby welght?

Please complete this field.

Baby Sex?

Please complete this field.

Baby Name?

Please complete this field.

Complications of Pregnancy (Please check all that apply)

Gestational Diabetes

Macrosomia

Multiple Gestation

Post Dates

Postpartum hemorrhage

Pre-eclampsia

Preterm Delivery

Other Complication

Please complete this field.

Pregnancy Details # 3

Delivery Date

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Weeks at Delivery

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Length of Labor (hrs)

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Epidural/Anesthesia

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Did you have Pre-term Labor?

Please complete this field.

Delivery Location?

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Who delivered your baby?

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Baby welght?

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Baby Sex?

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Baby Name?

Please complete this field.

Complications of Pregnancy (Please check all that apply)

Gestational Diabetes

Macrosomia

Multiple Gestation

Post Dates

Postpartum hemorrhage

Pre-eclampsia

Preterm Delivery

Other Complication

Please complete this field.

Current Medications (include hormones, herbs, vitamins, nonprescription medicine)

Name and Dosage

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Name and Dosage

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Name and Dosage

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Name and Dosage

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Name and Dosage

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Name and Dosage

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Allergies (please include all drug allergies)

List

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List

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List

Please complete this field.

List

Please complete this field.

List

Please complete this field.

List

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What is your problem today:

Describe your problem. Location / Quality / Severity / Duration / Timing / Context / Modifying Factors / Assoc. Signs & Symptoms:

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Since Your Last Visit:

Have you been diagnosed with a new medical problem since your last visit?

Yes

Please select an option.

Please Describe:

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Have you had any surgeries since your last visit?

Yes

Please select an option.

Please Describe:

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Have you been diagnosed with a new allergy?

Yes

Please select an option.

Please Describe:

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Do you have any new family history (parents, siblings, children)?

Yes

Please select an option.

Please Describe:

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Annual Care

Do you take Vitamin D – 1000-2000 units a day?

Yes

Please select an option.

Caffeine use - how many drinks per day?

Yes

Please select an option.

Have you seen your PCP in the last year?

Yes

Please select an option.

Did they do lab work?

Yes

Please select an option.

What year was your last Mammogram?

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Bone Density?

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Colonoscopy?

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Menstrual History

Are you menopausal?

Yes

Please select an option.

Have you had a hysterectomy?

Yes

Please select an option.

Are you currently pregnant?

Yes

Please select an option.

What was your age at your first menstrual period?

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Date of your last menstrual period:

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Are your periods regular (28-30 days)?

Yes

Please select an option.

If No, what is the interval between your periods? (Number of Days)

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How many days of bleeding do you have?

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How many heavy days?

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Do you have pain with your period?

Yes

Please select an option.

If Yes, how bad is that pain?

Minimal

Mild

Moderate

Severe

Please select an option.

Do you have a problem with heavy bleeding?

Yes

Please select an option.

Do you bleed after intercourse?

Yes

Please select an option.

Do you have bleeding between your periods?

Yes

Please select an option.

If Yes, how bad is that bleeding?

Light

Medium

Heavy

Please select an option.

Contraception

Are you in a sexual relationship?

Yes

Please select an option.

Male or Female?

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Do you have pain with intercourse?

Yes

Please select an option.

Are you trying to become pregnant?

Yes

Please select an option.

Do you have questions about sexual function, contraception, or infections?

Yes

Please select an option.

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