Patient History Intake Form

Patient Name

Date of Birth

Today's Date

Parent/Legal Guardian (if Minor)

What is the reason for your visit today?

Past Medical History

Medical Problem

Date of Onset

Add Additional Medical Problem

Female GYN History

First day of your last menstrual period?

Are you pregnant or any chance of being pregnant?

Yes No

Review of Symptoms

Check all that apply:

Constitutional

Weight Loss

Fatigue

Fever

Eyes

Glasses/Contacts

Eye Pain

Double Vision

Cataracts

Ear, Nose, Throat

Difficultly Hearing

Ringing in Ears

Vertigo

Sinus Trouble

Nasal Stuffiness

Frequent Sore Throat

Cardiovascular

Murmur

Chest Pain

Palpitations

Dizziness

Fainting Spells

Shortness of Breath

Difficulty Lying Flat

Swelling Ankles

Endocrine

Loss of hair

Heat/Cold Intolerance

Gastrointestinal

Heartburn/Reflux

Nausea/Vomiting

Constipation

Change in BMs

Diarrhea

Jaundice

Abdominal Pain

Black or Blood BM

Genitourinary

Burning/Frequency

Nighttime

Blood in Urine

Erectile Dysfunction

Abnormal Discharge

Bladder Leakage

Allergic/Immunologic

Hives/Eczema

Hay Fever

Psychiatric

Anxiety/Depression

Mood Swings

Difficult Sleeping

Hematology/Lymph

Easy Bruising

Gums Bleed Easily

Enlarged Glands

Musculoskeletal

Joint Pain/Swelling

Stiffness

Muscle Pain

Back Pain

Skin

Rash/Sores

Lesions

Itching/Burning

Neurological

Loss of Strength

Numbness

Headaches

Tremors

Memory Loss

Other

Females Only:

Age of Onset of Periods

Periods Regular?

Yes No

Number of Pregnancies

Allergies

Allergy Name (Medications, food, latex, dust, insects etc.)

Reactions and Symptoms

Treatment

Additional Allergies

Medications

Medication

Dosage (mg/mcg) and amount of times per day

Reason for Medication

Add Additional Medication

Preferred Pharmacy

Phone Number

Address

Family History

Has anyone in your family had any of the following conditions? (Please check and list relationship to you)

Heart Disease

Relationship

Diabetes

Relationship

High Cholesterol

Relationship

High Blood Pressure

Relationship

Bleeding Problems

Relationship

Blood Clots

Relationship

Stroke

Relationship

Asthma

Relationship

Kidney Disease

Relationship

Thyroid Disease

Relationship

Cancer

Type and Relationship

Mental Illness

Relationship

Alcohol/Drug Addition

Relationship

Other

Relationship

Social History

Recent Travel?

Yes No

Date of Travel

Date of Return to NY

Location

Do you smoke?

Yes No

If yes, how many packs a day?

Age Started?

When did you quit?

Do you Vape or Juule?

Yes No

If yes, how often?

Do you drink regularly?

Yes No

If yes, how many ounces per day?

Do you use recreational street drugs?

Yes No

If yes, which drug(s) & how often?

Are you sexually active?

Yes No

If yes, how many partners?

Do you use protection?

Yes No

Do you use seatbelts?

Yes No

Do you use helmets when riding your bike or scooter?

Yes No

Surgical History

Surgery

Date

Hospital

Add Another Surgery

Hospitalizations

Hospital

Date

Reason

Add Another Hospitalization

Patient Name

Date of Birth

Signature

Date

If Minor, Parent/Legal Guardian Name

Signature of Parent/Legal Guardian

Date

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