New Patient Questionnaire
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Date of birth
*
-
Month
-
Day
Year
Date
Current marital status
*
Please Select
Single
Married
Widowed
Divorced
Separated
Occupation
*
Do you smoke?
*
Yes
No
How much?
Do you drink alcohol?
*
Yes
No
How much?
What do you do for exercise?
*
Who is your primary care doctor?
*
When was the last time you had the following testing:
Cholesterol
Bone density
Pap
Mammogram
Colonoscapy
Are you having periods?
*
Yes
No
If so, when did the last one start?
If not, at what age did you stop having periods?
List your drug allergies
*
What pharmacy do you use?
*
List current medications
*
In the past two weeks have you:
Felt down, depressed or hopeless?
*
Yes
No
Had little interest or pleasure in doing things?
*
Yes
No
Poor appetite or overeating?
*
Yes
No
Felt tired or having little energy?
*
Yes
No
Felt bad about yourself?
*
Yes
No
Trouble sleeping (more than normal)?
*
Yes
No
Felt restless or like you were in slow motion?
*
Yes
No
Had trouble concentrating?
*
Yes
No
Had thoughts of harming yourself or others?
*
Yes
No
Please list your family medical history
*
Please list your personal medical history
*
Please list any surgeries you have had
*
How many pregnancies have you had?
*
# c-sections
# normal vaginal deliveries
# miscarriages
# stillbirths
# abortions
*
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
DOB
-
Month
-
Day
Year
Date
For Medicare Patients Only
Medicare will pay for a pap smear every other year. It is recommended of this office that you have yearly pap smears; however, we understand that financially it may not be feasible. The cost is $78 if Medicare does not pay for it, and if Medicare does not pay, your secondary will not pay. Please choose ONE of the following:
I DO NOT want my pap smear done this year if it was done last year.
I DO want my pap smear done this year.
(Please note that we will file all charges to Medicare and secondary insurances before billing you).
Submit
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