New Patient Registration (Form 2 of 3)

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 NameLast Name
Patient's Date of Birth*

MonthDayYear
In the last two weeks, have you been bothered by feeling nervous, anxious, or on edge?*

YesNo
In the last two weeks, have you been bothered by not being able to stop or control worrying?*

YesNo
In the last two weeks have you had a loss of interest or pleasure in doing things you used to like to do?*

YesNo
In the last two weeks have you felt sad, depressed or hopeless?*

YesNo
Have you been sexually active in the last 12 months?*

YesNo
If you have been sexually active, which partners have you been with? You may choose more than one.

One Male PartnerOne Female PartnerMultiple Male PartnersMultiple Female PartnersOther
Do you have any history of Sexually Transmitted Disease (STD)?*

YesNoOther
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?*

YesNo
Are you disabled?*

YesNo
Do you wear contacts or glasses?*

YesNo
Do you have a hearing impairment?*

YesNo
Do you have a Living Will and Advance Directive?
Have you had ALCOHOL in the past 12 Months?*

YesNo
If you have had alcohol, how often do you have at least one drink?
If you have had alcohol, how many drinks do you average per week?
Do you currently consume CAFFEINE more than once per month?*

YesNo
If you have had caffeine, how often do you consume it?
Do you currently use TOBACCO in any form?*

YesNo
Are you a former tobacco smoker?*

YesNo
Do you use RECREATIONAL DRUGS?*

YesNo
If you use recreational drugs, how often do you use them?
Do you use OTHER SUBSTANCES?*

YesNo
Please check off any GENERAL symptoms that you have, or had in the past year.

DepressionDizziness / FaintingFever / ChillsForgetfulnessHeadacheLoss of SleepLoss of WeightNervousnessNumbnessSweats
Please check off any CARDIOVASCULAR symptoms that you have, or had in the past year.

Chest PainHigh Blood PressureIrregular Heart BeatLow Blood PressurePoor CirculationRapid Heart BeatSwelling of AnklesVaricose VeinsOther
Please check off any EYE, EAR, NOSE, & THROAT symptoms that you have, or had in the past year.

Bleeding GumsBlurred VisionCrossed EyesDifficulty SwallowingDouble VisionEarache / DischargeHay FeverHoarsenessLoss of HearingNosebleedsPersistent CoughRinging in EarsSinus ProblemsSnoringVision Flashes / HalosOther
Please check off any GASTRO symptoms that you have, or had in the past year.

Poor AppetiteBloatingBowel ChangesConstipationDiarrheaExcessive HungerExcessive ThirstGasHemorrhoidsIndigestionNauseaRectal BleedingStomach PainVomitingVomiting BloodOther
Please check off any GENITO-URINARY symptoms that you have, or had in the past year.

Blood in UrineFrequent UrinationLack of Bladder ControlPainful UrinationOther
Please check off any REPRODUCTIVE HEALTH symptoms that you have, or had in the past year.

Abnormal Pap SmearBleeding Between PeriodsBreast LumpErection DifficultiesExtreme Menstrual PainHot FlashesLump in TesticlesNipple DischargePainful IntercoursePenis DischargeSore of PenisVaginal DischargeOther
Please check off any SKIN symptoms that you have, or had in the past year.

Bruise EasilyHivesRash / ItchingChange in MolesScarsSores That Won't HealAcneOther
Please check off the location of any MUSCLE & JOINT PAIN or NUMBNESS that you have, or had in the past year.

Arms / HandsHipsBackLegs / FeetNeckShouldersOther
When was the last time you saw a CARDIOLOGIST?
When was the last time you saw a DERMATOLOGIST?
When was the last time you saw a ENDOCRINOLOGIST?
When was the last time you saw an ENT?
When was the last time you saw a GASTROENTEROLOGIST?
When was the last time you saw a HEMATOLOGIST?
When was the last time you saw a NEPHROLOGIST?
When was the last time you saw a OBGYN?
When was the last time you saw a ONCOLOGIST?
When was the last time you saw a ORTHOPEDIST?
When was the last time you saw a PHYSICAL THERAPIST?
When was the last time you saw a PSYCHIATRIST?
When was the last time you saw a PULMONOLOGIST?
When was the last time you saw a RHEUMATOLOGIST?
When was the last time you saw a SLEEP SPECIALIST?
When was the last time you saw a UROLOGIST?
Have you had a DENTAL exam in the last year?*

YesNo
Have you had a VISION screening in the last year?*

YesNo
Have you had a MAMMOGRAM in the last year?*

YesNo
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.

AIDSAlcoholismAnemiaAnorexiaAppendicitisArthritisAsthmaBleeding DisorderBreast LumpBronchitisBulimiaCancerCataractsChemical DependencyChicken PoxDiabetesEmphysemaEpilepsyGlaucomaGoiterGonorrheaGoutHeart DiseaseHepatitisHerniaHerpesHigh CholesterolHIV PositiveKidney DiseaseLiver DiseaseMeaslesMigraine HeadachesMiscarriageMononucleosisMultiple SclerosisMumpsPacemakerPneumoniaPolioProstate ProblemsPsychiatric CareRheumatic FeverScarlet FeverStrokeSuicide AttemptThyroid ProblemsTonsillitisTuberculosisTyphoid FeverUlcersVaginal InfectionsVenereal DiseaseOther
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.

Clear
Please verify that you are a human being.*
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