New Patient Registration (Form 2 of 3)
Please complete this HEALTH HISTORY FORM to register as a new patient at Family Care, PA. Required fields are marked with a Red Asterisk. After you submit this form, you will be transferred to a third form to sign our Practice Policies. This is the 2ND OF 3 times you will complete a form, sign your name, and hit Submit before you will have completed your New Patient Registration.
Patient's Name
*
First Name
Last Name
Patient's Date of Birth
*
-
Month
-
Day
Year
In the last two weeks, have you been bothered by feeling nervous, anxious, or on edge?
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Yes
No
In the last two weeks, have you been bothered by not being able to stop or control worrying?
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Yes
No
In the last two weeks have you had a loss of interest or pleasure in doing things you used to like to do?
*
Yes
No
In the last two weeks have you felt sad, depressed or hopeless?
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Yes
No
Have you been sexually active in the last 12 months?
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Yes
No
If you have been sexually active, which partners have you been with? You may choose more than one.
One Male Partner
One Female Partner
Multiple Male Partners
Multiple Female Partners
Other
Do you have any history of Sexually Transmitted Disease (STD)?
*
Yes
No
Other
Please list any DRUG, FOOD, & OUTDOOR ALLERGIES you may have, including your normal reactions and previous events.
Please list the Name, Strength, Dosage, and Start Date for every MEDICATION you take on a consistent basis. This list should include OTC medications, supplements, and prescriptions from other providers.
Drug, Dose, # / Day, Start Date
Are you able to afford your medications?
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Yes
No
Are you disabled?
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Yes
No
Do you wear contacts or glasses?
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Yes
No
Do you have a hearing impairment?
*
Yes
No
Do you have a Living Will and Advance Directive?
Please Select
No, I don't want one.
No, but I do want one.
Yes, it is on file at Family Care.
Yes, I will provide a copy to Family Care.
What is this? I need more information.
Have you had ALCOHOL in the past 12 Months?
*
Yes
No
If you have had alcohol, how often do you have at least one drink?
Please Select
1 Day per Week
2 Days per Week
3 Days per Week
4 Days per Week
5 Days per Week
6 Days per Week
7 Days per Week
1-3 Days per Month
If you have had alcohol, how many drinks do you average per week?
Please Select
1 Drink per Week
2-3 Drinks per Week
3-5 Drinks per Week
6-7 Drinks per Week
8-10 Drinks per Week
11-14 Drinks per Week
15+ Drinks per Week
Rarely
Do you currently consume CAFFEINE more than once per month?
*
Yes
No
If you have had caffeine, how often do you consume it?
Please Select
1 Drink per Week
2-3 Drinks per Week
3-5 Drinks per Week
6-7 Drinks per Week
8-10 Drinks per Week
11-14 Drinks per Week
15+ Drinks per Week
Rarely
Do you currently use TOBACCO in any form?
*
Yes
No
Are you a former tobacco smoker?
*
Yes
No
Do you use RECREATIONAL DRUGS?
*
Yes
No
If you use recreational drugs, how often do you use them?
Please Select
1 Use per Week
2-3 Uses per Week
3-5 Uses per Week
6-7 Uses per Week
8-10 Uses per Week
11-14 Uses per Week
15+ Uses per Week
Rarely
Do you use OTHER SUBSTANCES?
*
Yes
No
Please check off any GENERAL symptoms that you have, or had in the past year.
Depression
Dizziness / Fainting
Fever / Chills
Forgetfulness
Headache
Loss of Sleep
Loss of Weight
Nervousness
Numbness
Sweats
Please check off any CARDIOVASCULAR symptoms that you have, or had in the past year.
Chest Pain
High Blood Pressure
Irregular Heart Beat
Low Blood Pressure
Poor Circulation
Rapid Heart Beat
Swelling of Ankles
Varicose Veins
Other
Please check off any EYE, EAR, NOSE, & THROAT symptoms that you have, or had in the past year.
Bleeding Gums
Blurred Vision
Crossed Eyes
Difficulty Swallowing
Double Vision
Earache / Discharge
Hay Fever
Hoarseness
Loss of Hearing
Nosebleeds
Persistent Cough
Ringing in Ears
Sinus Problems
Snoring
Vision Flashes / Halos
Other
Please check off any GASTRO symptoms that you have, or had in the past year.
Poor Appetite
Bloating
Bowel Changes
Constipation
Diarrhea
Excessive Hunger
Excessive Thirst
Gas
Hemorrhoids
Indigestion
Nausea
Rectal Bleeding
Stomach Pain
Vomiting
Vomiting Blood
Other
Please check off any GENITO-URINARY symptoms that you have, or had in the past year.
Blood in Urine
Frequent Urination
Lack of Bladder Control
Painful Urination
Other
Please check off any REPRODUCTIVE HEALTH symptoms that you have, or had in the past year.
Abnormal Pap Smear
Bleeding Between Periods
Breast Lump
Erection Difficulties
Extreme Menstrual Pain
Hot Flashes
Lump in Testicles
Nipple Discharge
Painful Intercourse
Penis Discharge
Sore of Penis
Vaginal Discharge
Other
Please check off any SKIN symptoms that you have, or had in the past year.
Bruise Easily
Hives
Rash / Itching
Change in Moles
Scars
Sores That Won't Heal
Acne
Other
Please check off the location of any MUSCLE & JOINT PAIN or NUMBNESS that you have, or had in the past year.
Arms / Hands
Hips
Back
Legs / Feet
Neck
Shoulders
Other
When was the last time you saw a CARDIOLOGIST?
Please Select
Never
0-4 Weeks Ago
1-3 Months Ago
4-6 Months Ago
7-12 Months Ago
1-2 Years Ago
3-5 Years Ago
6-10 Years Ago
11+ Years Ago
When was the last time you saw a DERMATOLOGIST?
Please Select
Never
0-4 Weeks Ago
1-3 Months Ago
4-6 Months Ago
7-12 Months Ago
1-2 Years Ago
3-5 Years Ago
6-10 Years Ago
11+ Years Ago
When was the last time you saw a ENDOCRINOLOGIST?
Please Select
Never
0-4 Weeks Ago
1-3 Months Ago
4-6 Months Ago
7-12 Months Ago
1-2 Years Ago
3-5 Years Ago
6-10 Years Ago
11+ Years Ago
When was the last time you saw an ENT?
Please Select
Never
0-4 Weeks Ago
1-3 Months Ago
4-6 Months Ago
7-12 Months Ago
1-2 Years Ago
3-5 Years Ago
6-10 Years Ago
11+ Years Ago
When was the last time you saw a GASTROENTEROLOGIST?
Please Select
Never
0-4 Weeks Ago
1-3 Months Ago
4-6 Months Ago
7-12 Months Ago
1-2 Years Ago
3-5 Years Ago
6-10 Years Ago
11+ Years Ago
When was the last time you saw a HEMATOLOGIST?
Please Select
Never
0-4 Weeks Ago
1-3 Months Ago
4-6 Months Ago
7-12 Months Ago
1-2 Years Ago
3-5 Years Ago
6-10 Years Ago
11+ Years Ago
When was the last time you saw a NEPHROLOGIST?
Please Select
Never
Within the last 30 days
1-3 Months Ago
4-6 Months Ago
7-12 Months Ago
1-2 Years Ago
3-5 Years Ago
6-10 Years Ago
11+ Years Ago
When was the last time you saw a OBGYN?
Please Select
Never
0-4 Weeks Ago
1-3 Months Ago
4-6 Months Ago
7-12 Months Ago
1-2 Years Ago
3-5 Years Ago
6-10 Years Ago
11+ Years Ago
When was the last time you saw a ONCOLOGIST?
Please Select
Never
0-4 Weeks Ago
1-3 Months Ago
4-6 Months Ago
7-12 Months Ago
1-2 Years Ago
3-5 Years Ago
6-10 Years Ago
11+ Years Ago
When was the last time you saw a ORTHOPEDIST?
Please Select
Never
0-4 Weeks Ago
1-3 Months Ago
4-6 Months Ago
7-12 Months Ago
1-2 Years Ago
3-5 Years Ago
6-10 Years Ago
11+ Years Ago
When was the last time you saw a PHYSICAL THERAPIST?
Please Select
Never
0-4 Weeks Ago
1-3 Months Ago
4-6 Months Ago
7-12 Months Ago
1-2 Years Ago
3-5 Years Ago
6-10 Years Ago
11+ Years Ago
When was the last time you saw a PSYCHIATRIST?
Please Select
Never
0-4 Weeks Ago
1-3 Months Ago
4-6 Months Ago
7-12 Months Ago
1-2 Years Ago
3-5 Years Ago
6-10 Years Ago
11+ Years Ago
When was the last time you saw a PULMONOLOGIST?
Please Select
Never
0-4 Weeks Ago
1-3 Months Ago
4-6 Months Ago
7-12 Months Ago
1-2 Years Ago
3-5 Years Ago
6-10 Years Ago
11+ Years Ago
When was the last time you saw a RHEUMATOLOGIST?
Please Select
Never
0-4 Weeks Ago
1-3 Months Ago
4-6 Months Ago
7-12 Months Ago
1-2 Years Ago
3-5 Years Ago
6-10 Years Ago
11+ Years Ago
When was the last time you saw a SLEEP SPECIALIST?
Please Select
Never
0-4 Weeks Ago
1-3 Months Ago
4-6 Months Ago
7-12 Months Ago
1-2 Years Ago
3-5 Years Ago
6-10 Years Ago
11+ Years Ago
When was the last time you saw a UROLOGIST?
Please Select
Never
0-4 Weeks Ago
1-3 Months Ago
4-6 Months Ago
7-12 Months Ago
1-2 Years Ago
3-5 Years Ago
6-10 Years Ago
11+ Years Ago
Have you had a DENTAL exam in the last year?
*
Yes
No
Have you had a VISION screening in the last year?
*
Yes
No
Have you had a MAMMOGRAM in the last year?
*
Yes
No
Describe your FATHER's Health Problems, if any.
Describe your MOTHER's Health Problems, if any.
Describe your SIBLING's Health Problems, if any.
Describe ANOTHER FAMILY MEMBER's Health Problems that may be relevant to you, if any.
Please check off every CONDITION you have had in your lifetime.
AIDS
Alcoholism
Anemia
Anorexia
Appendicitis
Arthritis
Asthma
Bleeding Disorder
Breast Lump
Bronchitis
Bulimia
Cancer
Cataracts
Chemical Dependency
Chicken Pox
Diabetes
Emphysema
Epilepsy
Glaucoma
Goiter
Gonorrhea
Gout
Heart Disease
Hepatitis
Hernia
Herpes
High Cholesterol
HIV Positive
Kidney Disease
Liver Disease
Measles
Migraine Headaches
Miscarriage
Mononucleosis
Multiple Sclerosis
Mumps
Pacemaker
Pneumonia
Polio
Prostate Problems
Psychiatric Care
Rheumatic Fever
Scarlet Fever
Stroke
Suicide Attempt
Thyroid Problems
Tonsillitis
Tuberculosis
Typhoid Fever
Ulcers
Vaginal Infections
Venereal Disease
Other
Please describe dates and circumstances of any SERIOUS ILLNESS OR INJURY.
Please describe dates and circumstances of any HOSPITALIZATIONS.
Please describe dates, complications, and outcomes of any PREGNANCIES.
I, the undersigned, certify that the information provided on this form is accurate and truthful. I have faithfully documented my medical history and understand that this information will be used by Family Care, PA to make medical decisions for me as a patient. I understand that a failure to report my full medical history accurately and truthfully could put me at serious risk and have not knowingly left out, misconstrued, or misrepresented any of the information on this form.
Please verify that you are a human being.
*
Submit
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