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New Patient Form

DEMOGRAPHICS

First and Last name
Month/Day/Year
Type Single, Married, Divorced or Widow(ed). If Married, type Married and the name of the spouse, and his/her age. Example: Married-Karen-50.
Ex. HP-203-324-4743/ WP-203-324-4747 or "n/a" for not applicable.
Ex. 203-324-4747 or "n/a" for not applicable.
Ex. medoylemd@optonline.net or "n/a" for not applicable.
Ex. 203-324-4743 or "n/a" for not applicable.
Name/Relationship and Number.
NAME, PHONE & FAX. Example: CVS Pharmacy/PH-698-4006/FAX-203-698-0454.

History of Present Illness/ Chief Complaint:

NOTE:We will start by focusing on ONE problem. All other problems will be addressed later in this form.

WHAT HAS HAPPENED SINCE THE PROBLEM STARTED (Symptoms, Drs seen, tests, treatments, etc.)

Briefly outline what has happened since the problem started. Follow the example below:

12/15- Seen Dr XYZ (PRIMARY CARE DOCTOR) for Weight Gain+Low Energy. Blood work + Thyroid Ultrasound. Diagnosed - Hypothyroid. Prescribed Armour Thyroid.

10/14- Seen Dr. ABC (PSYCHIATRIST) for Depression + Back Pain. Bloodwork came back normal. Diagnosed - Depression. Prescribed Antidepressant.

07/14- Gave Birth.

02/13- Seen Dr. QRS (NEURO) for Nerve pain. MRI Back and Lower Extremities. Diagnosed: Fibromyalgia. Prescribed: Celebrex.

01/12- Seen Dr SMITH (OBGYN) for Candida. Bloodwork came back Negative. NO Treatment.

06/11- Seen Dr. ROGER (DERMA) for ACNE. Prescribed Accutane.
Type n/a, if you have not seen any doctor.
Type name-specialty/town. Eg. "Smith-Norwalk/GYN." Type "none", if you have no current treating doctor.
Type none, if no treatments or medications have helped, OR if no treatments or medications have been tried.
Type none, if no treatment, medications or other factors have helped, OR if no treatments or medications have been tried.
Type none, if no treatment, medications or other factors that made this problem worse.
Describe this problem.

Medical History. List *ALL* Major Medical Problems and Hospitalizations. DO NOT LIST SURGERIES HERE.

(List surgeries in the next section).

Indicate if Resolved/Stable/Unresolved/Untreated/Worsening.

Ex: Diabetes-Metformin-Stable.
Ex: Hypothyroidism-Synthroid-Worsening.
Ex: Migraine-Unresolved/Untreated.

Surgical History:

Including VAGINAL DELIVERIES and C-SECTIONS. Follow this format:

2016- 3 Wisdom Teeth Extracted.
2015- Vaginal Delivery.
2014- CSection.
2013- Appendectomy.
2012- Tonsillectomy.

Medications:

List your medications ONLY. Follow this format:
Medication - Dose - Frequency.

Example: Armour Thyroid - 30mg. - Every Morning.
Example: Cortef - 5mg - Twice Daily.
Example: Amoxicillin - 1000mg - Once Daily.
List your supplements ONLY. Follow this format:
Supplements - Dose - Frequency.

Example: Adrenal Complex - 2 tabs - Daily.
Example: Vitamin C - 2000 mg - Daily.

Allergies:

Medication and reactions Example: Penicillin-Rash.
List all other allergies. Type none if you have no other allergies. (Environmental, Seafood, Weeds, Grass, Dust, Mites, etc.)
Type your sensitivities and reactions. Example:Iron - stomach ache.

Family History:

List all MAJOR medical conditions. Follow this format. Living/Deceased-Age-Conditions. Do not include heart attack if it took place after age 60.

Example: Living-60. Hypertension. Hypothyroidism. ADHD. Dementia.
Example: Deceased-56. Hypertension. Diabetes.
Example: Deceased-56. Heart Attack.
Example: Living-Age Unknown. I am adopted.
List all MAJOR medical conditions. Follow this format. Living/Deceased-Age-Conditions. Do not include heart attack if it took place after age 60.

Example: Living-60. Hypertension. Hypothyroidism. ADHD. Dementia.
Example: Deceased-56. Hypertension. Diabetes.
Example: Deceased-56. Heart Attack.
Example: Living-Age Unknown. I am adopted.
List all MAJOR medical conditions. Do not include heart attack if it took place after age 60. Type n/a for NOT APPLICABLE.
List all MAJOR medical conditions. Do not include heart attack if it took place after age 60. Type n/a for NOT APPLICABLE.
List all MAJOR medical conditions. Do not include heart attack if it took place after age 60. Type n/a for NOT APPLICABLE.
List all MAJOR medical conditions. Do not include heart attack if it took place after age 60. Type n/a for NOT APPLICABLE.
List all MAJOR medical conditions. Do not include heart attack if it took place after age 60. Type n/a for NOT APPLICABLE.

Social History:

Please provide your History of smoking by following the format below:

Ex: Quit-2015. Smoker for 10 yrs. 1 pk a day.
Ex: Quit-2010. Smoker for 5 yrs. 1/2 pk a day.
Ex: Quit-Last Month. Smoker for 1 month. 5 cigarettes/day.
Type never, rare, occasional or # per week. Type wine, liquor, past alcohol abuse and any other details.
Type none, if you have no children.
Type N/A if not applicable
Type none, if patient is not a minor.
Indicate school as well.
Type n/a, if currently not working.
Type none, if you are single or if spouse is not working.
Type none, if you have no hobbies.
Type none, if you have no religion.
Type none, if you dont have major childhood events or trauma.

Diet / Foods Regularly Eaten:

TESTS:

Ex: 2017-Ultrasound-NORMAL.
Ex: 2016-Biopsy-ABNORMAL.
Ex: 2015-US-Nodule.

Review of Systems:

If not taking any medication for mood problems, type NONE.
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