Patient Intake Forms

Patient Information

Date

Home Phone

Cell Phone

SS #

Last Name

First Name

Middle Name

Address

City

State

Zip

Birth Date

Sex

Male Female

Patient Employer

Employer Address

Phone

Occupation

Whom may we thank for referring you?

In case of emergency

Phone

DISCLAIMER: 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 of Patient, Parent, or Guardian

Date

Name of Patient, Parent, or Guardian

Relationship to Patient

Patient Personal Health History

Today's Date

The information contained herein is confidential and will not be released unless you authorize us to do so. Answer all questions to the best of your knowledge.

Name: Last

First

Middle

Date of Birth

Age

Height

Weight

PHYSICIAN INFORMATION

Referring Physician

Address

Date of your last physical exam

HEALTH HISTORY

Do you have or have you had (if yes, give date of occurence)

AIDS or HIV

Yes No

Congenital Heart Disease

Yes No

Kidney Disease

Yes No

Arthritis

Yes No

Depression

Yes No

Leukemia

Yes No

Asthma

Yes No

Diabetes

Yes No

Migraine

Yes No

Back Problems

Yes No

Dry Eye

Yes No

Pneumonia

Yes No

Bladder Infection

Yes No

Prostatitis

Yes No

Scleroderma/Lupus

Yes No

Bleeding Tendency

Yes No

Hay Fever

Yes No

Stomach Ulcer

Yes No

Bronchitis

Yes No

Heart Attack

Yes No

Stroke

Yes No

Cancer

Yes No

Hepatitis

Yes No

Thyroid Disease

Yes No

Colitis

Yes No

High Blood Pressure

Yes No

Tuberculosis

Yes No

Epilepsy

Yes No

For items where yes is selected, kindly provide additional information with dates here.

Other serious illnesses which you have had and when

Serious accidents and injuries and when

DAILY HABITS

Do you regularly smoke?

Yes No

If yes, how much?

Do you regularly drink 6 or more cups of coffee, cola, tea per day?

Yes No

Do you regularly drink alcohol?

Yes No

If yes, how much?

BLEEDING

Do you frequently have bleeding gums, bruising or nose bleeds?

Yes No

Have you had blood transfusions?

Yes No

If yes, when?

MEDICATIONS

Medications (prescription and non-prescription) that you have taken within the last month if not noted above:

Add medication

Name of drugs to which you are allergic (incluing latex)

FAMILY HISTORY

Do you know of any blood relative who has or had (check and give relationship)

Arthritis

Other Cancer

Heart Attack

Relationship

Bleeding Tendency

Diabetes

High Blood Pressure

Relationship

Breast Cancer

Epilepsy

High Fever after Surgery

Relationship

SURGERY HISTORY

List the names and years of any operations or surgeries you have ever had:

Have you ever had any complications from anesthesia?

Yes No

If yes, explain.

WOMEN ONLY

Is there any chance you may be pregnant?

Yes No

Are you still having regular monthly menstrual periods?

Yes No

How many pregnancies?

Date of last pap smear

Results

Date of last mammogram

Results

Note: We recommend regular breast and pelvic exams by your regular physician or gynecologist

MEN ONLY

Is there a discharge from your penis?

Yes No

Have you ever had prostate trouble?

Yes No

The above information is true to the best of my knoweldge.

Patient or Responsible Party's Signature

Date

Your information will be encrypted.

Patient Intake Forms

Patient Information

Patient Personal Health History

Stephen J. Pincus, M.D., F.A.C.S.