North Franklin Internal Medicine & Pediatrics Clinic: Adult New Patient Questionnaire



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North Franklin Internal Medicine & Pediatrics Clinic: Adult New Patient Questionnaire
Patient Name: Date of Birth: _____________
Spouse/Partner: ______________________________________________________________Height: Weight: ___________
Children: Name Male/Female Age: Name Male/Female Age: _____
Name Male/Female Age: Name Male/Female Age: _____
Name Male/Female Age: Name Male/Female Age: _____


Illnesses/Medical Problems-Past & Present (e.g. seasonal allergies, heart disease, hypertension)

Date of Onset

Operations or Injuries


Date

















































































































Current Medications (include over-the-counters, supplements, herbals, etc.)

Dosages

Current Medications(continued)


Dosages

(continued)



Drug Allergies and/or Reactions

























































































































Immunizations: Tetanus Influenza Pneumovax (Pneumonia)

(Date of last shot/test) TB Test: Hepatitis A: Hepatitis B: __________ Measles: Rubella: Varicella (Chickenpox):___________

When were your most recent HEALTH MAINTENANCE screening tests?
Lipid (cholesterol): Results: PSA (prostate cancer): Results: _________
Colonoscopy/Sigmoidoscopy/stool blood test: ______________ Results: __________________
Bone Density Test: Results: Mammogram: Results: _____________
Ever Abnormal Results: Details: _____________________________________

Family History

Age

Deceased?

Illnesses and/or Cause of Death

Are any of the following illnesses in the family?
Heart Attacks

 Cancer


 Strokes

 High Cholesterol

 High Blood Pressure

Diabetes

 Allergies or Asthma

 Seizures / Epilepsy

 Mental Illness (Depression)

 Kidney Disease

Breathing Problems

 Birth Defects

 Alcoholism

 Bleeding / Clotting Problems


(FLIP FORM OVER)

Mother










Father










Brother/Sister










Brother/Sister










Brother/Sister










Brother/Sister










Child #1










Child #2










Child #3










Child #4










Mom’s Mom










Mom’s Dad










Dad’s Mom










Dad’s Dad









Patient Name: ______________________________________

Systems Review: Are you troubled by any of the following?

General YES NO

Unexplained Weight Loss or Gain   Intestinal System (continued) YES NO

Excessive Thirst   Heartburn  

Excessive Fatigue   Frequent Indigestion  

Night Sweats / Frequent Fevers  

Genitourinary System

Painful Urination  

Passing Blood  

Skin and Hair Poor Bladder Control  

Any skin or Hair Problem   Weak Urine Stream  

Difficulty Hearing / Ringing in Ears   Urination more than once a night  

Problems with Teeth / Gums   Unusual Vaginal Bleeding  

Hay Fever / Seasonal Allergies / Rhinitis   Discharge from penis or vagina  

Nose problem  

Hoarseness   Skeleton and Joints

Trouble Swallowing   Pain in Joints  

Swelling in Joints  

Heart and Lungs Morning Joint Stiffness greater than 30 minutes  

Frequent Cough  

Shortness of Breath   Back Trouble  

Coughing up Blood  

Chest Pain / Pressure / Heaviness   Nervous System

Wheezing   Severe or Frequent Headaches  

Chest Discomfort with Exercise   Numbness of Hands and Feet  

Irregular Heart Beat   Uncontrollable Tension  

Other Heart Trouble   Increased Irritability  

Ankle Swelling   Feelings of Being “Blue”  

Thoughts of hurting yourself or others  

Intestinal System Memory Problems  

Appetite Loss   Loss of Coordination  

Frequent Belching  

Abdominal Pain   Personal Problems

Frequent Nausea and Vomiting   Problems with sexual relations?  

Change in Bowel Habits   Have you had psychiatric help?  

Persistent Constipation   Do you desire psychiatric help?  

Frequent Diarrhea  

Rectal Bleeding  
Social History Other Concerns

Tobacco Use Caffeine Intake:  None  Coffee/ Tea: cups per day

Cigarettes  Never  Quit Date:  Sodas: /day  Chocolate: oz./day

 Current Smoker packs/day #of years

Other Tobacco:  Pipe  Cigar  Snuff  Chew WEIGHT: Are you satisfied with your weight?  No  Yes

Are you interested in quitting?  Yes  No

DIET: How do you rate your diet?  Good  Fair  Poor

Alcohol Use Do you take supplements? .

Do you drink alcohol?  No  Yes # drinks per week: _____ Do you drink 4 lg. glasses of milk daily or take CALCIUM supplements?

Type of alcohol? ____________________________  No  Yes

Is your alcohol use a concern for yourself or others?  No  Yes

EXERCISE: Do you exercise regularly?  No  Yes

Drug Use What kind of exercise? .

Do you use any recreational drugs?  No  Yes How long (minutes) How often? .

Have you EVER used needles?  No  Yes If you do not exercise, why? .
Sexual Activity BIKE HELMET: Do you use a helmet?  No  Yes

Sexually Active:  No  Yes  Not Currently

Birth Control Method:  None Needed SEAT BELT: Do you use seatbelts consistently?  No  Yes
Have you ever had any sexual transmitted diseases? (STD’S) Do you feel safe at home?  No  Yes

 No  Yes Have you ever been ABUSED?  No  Yes

Are you interested in being screened for sexually transmitted Do you have a GUN in your home?  No  Yes

diseases (STD’S)?  No  Yes


FOR WOMEN ONLY FOR MEN ONLY

Ever had an abnormal pap smear?  No  Yes Have you had any of the following?

If yes, when? . Sore on penis  No  Yes

Are your periods irregular?  No  Yes Swelling or tenderness in scrotum  No  Yes

Do you bleed in between periods?  No  Yes Any problems with sexual function  No  Yes

Do you have an IUD?  No  Yes Any problems having children  No  Yes

When was your last period? . “Prostate Trouble”  No  Yes

How long between beginning of one period and the next? . Ever had a vasectomy  No  Yes



How many days do you flow? . Ever had an instrument passed into the bladder  No  Yes

Flow Amount:  Very Little  Moderate  Heavy


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