New Patient Medical History Form (Endocrine)

Patient Name:

Age:

Date of Birth:

Reason for Visit:

Today's date:

Primary Care Provider:

Referring Provider:

Any other provider that you see on a regular basis:

History of cancer: When and where

Please list all surgeries and procedures:

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Personal & Social History:

Highest Education Level: If Grade, specify:

Occupation: If Employed, where:

Recreational Drug Use: If Former user, quit:

What drugs have you used or currently use: If other, specify:

Do you use or have used Marijuana including Medical Marijuana:

YES NO

Smoking History:

Current Smoker Former Smoker Never Smoker

How long have you been smoking?

When did you quit?

How Many years did you smoke?

Have you ever chewed tobacco?

YES NO

Family History:

Please list your allergies/adverse reaction to medications:

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Medication History:

IF YOU HAVE A LIST OF YOUR CURRENT MEDICATIONS PLEASE GIVE TO THE MEDICAL ASSISTANT. IF NOT PLEASE FILL BELOW. PLEASE INCLUDE PRESCRIPTION/OVER THE COUNTER MEDS/VITAMINS/SUPPLEMENTS

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If there is anything else that you want to discuss, please list here:

Person providing information:

Date

Fill out this page only if you are being referred for Diabetes.

How long have you had Diabetes?

Have you seen an endocrinologist in the past?

Yes No

if Yes, who:

Are you taking insulin to control your diabetes?

Yes No

; If yes, how long you have been on insulin?

Have you taken other medications to control your diabetes that you have stopped now? Why?

How many times you have visited ER or hospitalized for blood sugar problems in the last year?

Any episodes of Diabetes Ketoacidosis (DKA)?

Yes No Do not know what that is.

If Yes, when:

What is your most recent HbA1c:

When was that tested?

Do not know what HbA1c is

MONITORING HISTORY

Do you check your blood sugars?

Yes No

Which meter/sensor do you use?

What range do your sugars fall in?

Have you had blood sugar > 400 in the last 3 months?

Yes No

If yes, How often:

Have you had low blood sugars (< 70) in the last 3 months?

Yes No

If yes, How often:

How do you treat a low blood sugar episode?

COMPLICATION HISTORY

Do you see an Eye Doctor?

Yes No

Name:

Last eye exam:

Diabetic eye disease?

Yes No

History of laser treatment?

Yes No

Do you have history of kidney disease?

Yes No

Name of kidney specialist:

Do you have neuropathy or nerve disease from diabetes?

Yes No

Do you see a podiatrist?

Do you have Heart Disease?

Yes No

Name of cardiologist:

Have you been screened or diagnosed with sleep apnea?

Yes No

If yes:

Do you snore loudly (louder than talking or loud enough to be heard through closed door?

Yes No

Do you often feel tired, fatigued, or sleepy during the daytime?

Yes No

Has anyone observed that you stop breathing during your sleep?

Yes No

Do you have any sexual problems?

Yes No

Have you tried any medications?

Yes No

Have you tried any medications: If yes, Please list:

LIFESTYLE MANAGEMENT

Have you ever seen a diabetic educator or attended a group diabetes program?

Yes No

If yes, When/where:

How many times do you eat in a day?

Meals

what are the timings?

Snacks:

what are the timings?

Do you exercise regularly?

Yes No

How often?

For how long?

List any problems with exercise:

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