Questionnaire

The information you provide on this form will help us get to know you better so we can hit the ground running at your first appointment.

Please list any past or current medical conditions:

Please list any surgeries you have had:

FAMILY HISTORY

Please indicate medical conditions in your immediate family:

Mother:

Father:

Sister:

Brother:

SOCIAL HISTORY

Occupation:

Retired:

Disability:

Marital status:

Race/Ethnicity:

LIFESTYLE

Do you or did you smoke?

How many packs per day?

How long?

When did you quit?

Do you drink alcohol?

How often?

Have you ever or are you currently using illicit drugs?

If yes, please explain:

MEDICAL HISTORY

Please list all medications you are currently taking and why:

Medication / dosage

Reason for medication

Please list any medication allergies:

Medication name

Reaction

REVIEW OF SYSTEMS

Please check Yes or No to the following health questions, past or present:


Cardiovascular (Heart disease, high blood pressure, CHF)

Gastrointestinal (GERD, IBS, diverticulitis, liver disease)

Genitourinary (Kidney stones, incontinence, enlarged prostate)

Hematologic (Anemia, blood clots, easy bruising)

Metabolic (Diabetes, thyroid disease, high cholesterol)

Musculoskeletal (Arthritis, lupus, fibromyalgia, back pain)

Neurologic (Seizures, headaches, tremors, fainting spells, stroke)

Oncologic (Cancer, leukemia, lymphoma)

Psychological (Depression, anxiety, sleep disorders)

Respiratory (Asthma, COPD, chronic cough)

Skin (Psoriasis, rashes, edema)

PREVENTIVE SERVICES

Have you had any of the following:

Immunizations:

Physical exam

Cholesterol check

Colonoscopy

Bone density test

Pneumonia vaccine

Shingles vaccine

Flu shot

Tetanus booster

COVID-19 vaccine

COVID-19 booster

FEMALES ONLY

When was your last mammogram?

When was your last Pap smear?

Have you gone through menopause?

Have you taken hormone replacement?

DIABETICS

What was your last hemoglobin A1c level?