New Patient Information

Patient Interview Form

First Name

Last Name

Date of Birth

Email

Please check one as your preferred email for communications

Personal

Work

Contact Preference

Cell phone Letter Email

Contact Phone Number

Preferred Language

English Spanish; Castilian Other

If other, please specify.

Pharmacy

Name

Address

Phone

Allergies

Patient has no known drug allergies

Adhesive Tape

Codeine Sulfate

Erythromycin

Penicillin

Shellfish

Iv Dye, Iodine Containing

Latex gloves

Add Additional Allergies

Current Medications

None

Add Additional Medications

Do you take aspirin daily?

Yes No

Do you take blood thinners?

Yes No

If yes, who prescribes them for you?

Consent to Import Medication History

I consent to obtaining a history of my medications purchased at pharmacies.

Yes No

Immunizations

None

Add new row

Diagnostic Studies/Tests

None

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Previous Procedures

None

Add new row

History of difficult intubation?

Yes No

History of difficult IV start?

Yes No

Past or Present Medical Conditions

None

Gastroenterology/Hepatology

Add new row

Cardiology

None

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Pulmonology

None

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Other

Social History

Occupation

Number of Children

Alcohol

Type:

Beer

Wine

Liquor

Quantity

Number

Frequency

Caffeine

Tobacco

SMOKING STATUS

Current every day smoker

Current some day smoker

Former smoker

Never smoker

Smoker, current status unknown

Light tobacco smoker

Heavy tobacco smoker

Unknown if ever smoked

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Drug Use

None

Add new row

Exercise

None

Light exercise

Moderate exercise

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Family Medical History

No knowledge of family history

Add new row

Health Status

Add new row

Review Of Systems

Height

Weight

Consent to Import Medication History

I consent to obtaining a history of my medications purchased at pharmacies

Yes No

Consent to Share Data

I consent to having my medical and demographic information shared with other health care entities.

Yes No

Reminder Preference

I would like to receive preventive care and follow up care reminders.

Yes No

Reviewed with

Patient

Parent

Guardian

Not Present

By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

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