NEW PATIENT HEALTH QUESTIONNAIRE
NEW PATIENTS ONLY. Please make sure you fill out all THREE (3) forms labeled "New Patient" (see list on the left). Submit all 3 forms: NEW PATIENT (1) REGISTRATION; NEW PATIENT (2) HEALTH QUESTIONNAIRE; and NEW PATIENT (3) ANNUAL HEALTH SCREENINGS. If you are a new patient with Medicare insurance, please also complete form (4) NEW PATIENT - MEDICARE
Select all that apply.
Please list any current or past medical problems, along with the approximate year they occurred (or indicate "NONE").
Please list any hospitalizations and the approximate year they occurred, including surgeries (or indicate "NONE").
Please list any other physicians you are currently seeing and the reason that you see them (or indicate "NONE"). For example, an endocrinologist that you see for diabetes.
MEDICATIONS
List all medications you are taking (including over-the-counter, vitamins, herbs & birth control). List the MEDICATION, the DOSAGE, and HOW OFTEN YOU TAKE IT. (Or indicate "NONE" if you don't take any medications)
FAMILY HISTORY
PLEASE ANSWER THE FOLLOWING REGARDING THE MEDICAL HISTORY OF YOUR BIOLOGICAL FAMILY.
Father
Check all that apply.
If your father has a history positive for any type of cancer, please list the type of cancer and the approximate age at diagnosis. Also, please list any other significant medical issues not indicated above.
Mother
Check all that apply.
If your mother has a history positive for any type of cancer, please list the type of cancer and the approximate age at diagnosis. Also, please list any other significant medical issues not indicated above.
Siblings
Indicate whether your siblings are living or deceased. If any are deceased, list approximate age at death. If you have no siblings, enter NONE.
Check all that apply.
If any of your siblings have a history positive for any type of cancer, please list the type of cancer and the approximate age at diagnosis. Also, please list any other significant medical issues not indicated above.
Grandmother (Mother's Side)
Check all that apply.
If your maternal grandmother has a history positive for any type of cancer, please list the type of cancer and the approximate age at diagnosis. Also, please list any other significant medical issues not indicated above.
Grandfather (Mother's Side)
Check all that apply
If your maternal grandfather has a history positive for any type of cancer, please list the type of cancer and the approximate age at diagnosis. Also, please list any other significant medical issues not indicated above.
Grandmother (Father's Side)
Check all that apply.
If your paternal grandmother has a history positive for any type of cancer, please list the type of cancer and the approximate age at diagnosis. Also, please list any other significant medical issues not indicated above.
Grandfather (Father's Side)
Check all that apply.
If your paternal grandfather has a history positive for any type of cancer, please list the type of cancer and the approximate age at diagnosis. Also, please list any other significant medical issues not indicated above.
Other Family Members
Are there any other family members who have suffered from diabetes, high blood pressure, high cholesterol, heart disease, cancer, or any other conditions you feel are important? FOR ANY HISTORIES OF CANCER, please indicate type of cancer and approximate age at diagnosis
HEALTH MAINTENANCE
Please indicate the approximate date (year) of the last time you had the following medical services. If you have never had them or it doesn't apply to you, enter NONE or N/A. If you are unsure if you have ever had it, enter UNSURE.
SOCIAL HISTORY
HEALTHCARE WISHES
Most healthy patients would like to be treated aggressively (such as CPR, respirator, ICU, etc) if they had a potentially curable condition.
If you were unable to make your own healthcare decisions (for instance, you were in a coma from a car accident), whom would you want us to ask about what your wishes would be? Please name one person and one alternate. You can also fill out a healthcare proxy form.
Click SUBMIT FORM and then complete the last form called "NEW PATIENT (3) - HEALTH SCREENINGS"