Health History

Full Name

Date:

Reason for today’s visit:

Previous care provided by:

How did you hear about our practice?

In the past 2 weeks, have you been bothered by:

Little interest or pleasure in doing things?

Yes No

Feeling down, depressed or hopeless?

Yes No

Review of Symptoms: Please choose any persistent symptoms you have had the past few months. Read through every section and choose “No problems” if none of the symptoms apply to you.

Women only:

Pre-menstrual symptoms

Problem with menstrual periods

Hot flashes

Night sweats

No problems

Immunizations:

If yes, list the year if known

Personal Information:

First Name:

Last Name:

Middle Initial:

Date of Birth:

Address:

City:

State:

ZIP:

Home Phone:

Work Phone:

Cell Phone:

Other Names Used:

E-mail:

Gender:

SSN:

Language:

DL:

Marital Status:

Ethnicity:

Race:

Previous PCP:

Phone:

Emergency Contact:

First Name:

Last Name:

Middle Initial:

Date of Birth:

Address:

City:

State:

ZIP:

Home Phone:

Work Phone:

Cell Phone:

Pharmacy Information:

Name:

Phone:

Fax:

Address:

City:

State:

ZIP:

Advanced Directive:

Choose all that apply, and provide copies for our records.

Do Not Resuscitate

Durable Power of Attorney

Living Will

HC Proxy

I / we do hereby consent to and authorize the performance of all treatments, surgeries and medical services deemed advisable by the physicians and staff of Langer Family Medicine, PA to me or to the above-named minor of whom I am the parent or legal guardian. I hereby certify that to the best of my knowledge, all statements contained hereon are true. I understand that I am directly responsible for all charges incurred for medical services for myself and my dependents regardless of insurance coverage. I furthermore agree to pay legal interest, collection expenses, and attorneys’ fees incurred to collect any amount I may owe. I also hereby authorize Langer Family Medicine, PA to release information requested by insurance companies and / or its representatives. I fully understand this agreement and consent will continue until canceled by me in writing.

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

Signature of Patient / Responsible Party:

Date:

Relationship:

Medication:

List all medications you are currently taking, including both prescription and non-prescription, and the dosage.

Add new medication

Medication Allergies:

List all known medication allergies.

Medical History:

List if you have ever experienced specific illnesses/chronic medical conditions, and the year of onset.

Add Illness / Chronic Medical Condition

Surgical History:

List any surgeries you have had, and the year preformed.

Add Surgical Procedure

GYN History:

What age did you start having periods:

Date of menopause (if applicable):

Last menstrual cycle:

Number of Pregnancies:

Date and Type of Delivery:

Add new row

Any Complications during delivery:

Health Maintenance:

Choose below if you have received the following, and the date of most recent exam.

Exam / Procedure:

Colonoscopy

Eye Exam

Lipid Panel (Cholesterol)

Physical / Wellness Exam

DEXA Scan

GYN Exam

Mammogram

Breast Exam

PAP Test

Date of most recent Colonoscopy:

Date of most recent Eye Exam:

Date of most recent Lipid Panel (Cholesterol):

Date of most recent Physical / Wellness Exam:

Date of most recent DEXA Scan:

Date of most recent GYN Exam:

Date of most recent Mammogram:

Date of most recent Breast Exam:

Date of most recent PAP Test:

Family History:

Choose all that apply, and list family member affected.

If you checked Ovarian Cancer, list family member affected:

If you checked Breast Cancer, list family member affected:

If you checked Colon Cancer, list family member affected:

If you checked Cervical Cancer, list family member affected:

If you checked Prostate Cancer, list family member affected:

If you checked Melanoma, list family member affected:

If you checked Alzheimer’s Disease, list family member affected:

If you checked Depression, list family member affected:

If you checked Diabetes, list family member affected:

If you checked Hypertension, list family member affected:

If you checked High Cholesterol, list family member affected:

If you checked Heart Disease, list family member affected:

If you checked Stroke, list family member affected:

If you checked Thyroid Disease, list family member affected:

If you checked Other, list family member affected:

Social History:

Occupation:

Employer:

Children:

Yes No

How Many:

Male(s):

Female(s):

Tobacco Use:

Yes No

Packs Per Day:

Year Quit:

Alcohol Use:

Yes No

How Often:

Type:

Exercise:

Yes No

Intensity:

Duration:

Caffeine Use:

Yes No

How Often:

Type:

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