Cnyfamilycare - ADULT NEW PATIENT HISTORY FORM

ADULT NEW PATIENT HISTORY FORM
Today's Date

Month Day Year
Date
Patient Name
Date of Birth

Month Day Year
Date
SS#
Sex at Birth

Male Female
Current Sex

Male Female
Current Gender Identification

Male Female Transgender Male Transgender Female Non-Binary
Patient Email Address
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Ext.
Who completed this form?

Patient Spouse Other, Name (if other than patient)
Emergency Contact
Name
Relationship
Phone Number
Please enter a valid phone number.
Insurance
Primary Insurance Carrier
Policy Holder Name
Policy Number
Your relation to Policy Holder
SECONDARY Insurance Carrier
Policy Holder Name
Policy Number
Your relation to Policy Holder
The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the physician. I understand that I am financially responsible for any balance not covered by my insurance. I also authorize CNY Family Care or insurance company to release any information required to process claim.
Patient Signature

Clear
Date

Month Day Year
Date

Care Provider
Former Care Provider Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Gynecologist (If applicable)
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Please list below any specialists you see, OR have seen, and their contact information (phone number, address):

ADVANCE DIRECTIVES
Do you have a living will?

Yes No
Do you have a health care proxy?

Yes No
Name
Phone Number
Please enter a valid phone number.
Have you designated someone "Power of Attorney”?

Yes No
Name
Phone Number
Please enter a valid phone number.
Have you issued an order indicating "Do Not Resuscitate" (DNR)?

Yes No
IMPORTANT: We ask that you bring your physician a copy of any documentation you have available regarding the above advance directives at your first appointment.
IMMUNIZATION HISTORY

Have you received the following IMMUNIZATIONS? If yes, indicate the approximate year it was last given:

	Unknown	Yes	No	Year
Hepatitis A
Hepatitis B
Tetanus / Diphtheria
Influenza (Flu)
Shingles

IMPORTANT: We ask that you bring a copy of your immunization record with you to your first appointment.
ALLERGIES

Have you had an allergic reaction to?

	Yes	No
Iodine or X-ray contrast dye
Latex
Bee or wasp stings
Adhesive tape

Have you had hives, skin rash, breathing problems, or other allergic reactions to medications?

Yes No
If yes, please describe
Are there medications, other than those you are allergic to, that you would prefer not to use due to prior unpleasant side effects (example: GI upset)?

Yes No
If yes, please describe
Do you have any food allergies?

Yes No
Food Allergies

Cow's Milk Eggs Tree Nuts Peanuts Shellfish Wheat Soy Other food allergy

MEDICATIONS
Are you currently taking any prescription and/or non-prescription medications including vitamins, nutritional supplements, birth control, pain relievers, diuretics, laxatives, and herbal remedies?

Yes No
List medications below
HEALTH MAINTENANCE HISTORY

Have you received the following HEALTH MAINTENANCE? If yes, indicate date of last exam/ test and who performed.

	Unknown	Yes	No	Date	Where
Bone Density Test / DEXA
Cardiac Stress Test
Cologuard
Colonoscopy
Dental Exam
Eye Exam
EKG
Hepatitis C Screening
Mammogram
PSA Test (prostate blood test)
PAP Test
Pelvic Exam
Physical (complete) exam
Rectal Exam
Sleep Study
Tuberculosis (TB) Test

CHILDHOOD ILLNESS

Indicate if you have had
Any serious childhood Illnesses?

None Chickenpox Measles Meningitis Mumps Pertussis Poliomyelitis Rheumatic Fever Rubella Other

Medical Problems Review

Have you ever had any of the following?

	No	Yes	Describe the problem when appropriate
Abnormal chest x-ray
Abnormal PAP Test
Alzheimer’s or Dementia
Anxiety, depression, or mental illness
Blood problems (abnormal bleeding, anemia, clots, high or low white count)
Diabetes
Growth removed from the colon or rectum (polyp or growth)
Heart Attack (Dates)
High blood pressure
High cholesterol or triglycerides
HIV/ AIDS
Mononucleosis
Multiple Sclerosis
Parkinson’s
Pacemaker or AICD (Internal Defib)
Scarlet Fever or Rheumatic Fever
Sexually transmitted disease
Shingles
Stroke or TIA
Treatment for alcohol and/or drug abuse
Tuberculosis or positive tuberculin skin test
Cosmetic or plastic surgery

Have you ever had a serious Accident(s)/ Injury(ies)?

NO Auto Accident Head Injury Work Injury Sports Injury Other

Indicate whether you have ever had a MEDICAL PROBLEM AND/OR SURGERY related to each of the following by placing a check (√) in the appropriate boxes. If you have had surgery, indicate the approximate year(s) of surgery. Describe the problem and type of surgery. Circle the appropriate choice when multiple choices are listed in a question.

	No Problem	Medical Problem	Had Surgery	Year(s) of Surgery	Describe
Eyes (cataracts, glaucoma)
Ears, nose, sinuses, tonsils
Thyroid or parathyroid glands
Heart valves, heart rhythm
Coronary (heart) arteries (angina)
Arteries (aorta, arteries to head, arms, legs)
Veins, blood clots in the veins
Lungs (COPD, Emphysema)
Esophagus or stomach (ulcer)
Bowel (small & large intestine) Appendix)
Liver or gall bladder (including Hepatitis)
Hernia
Kidneys or bladder
Bones, joints, muscles (fractures)
Back, neck, spine
Brain (seizure disorder, Migraines)
Skin (cancer, eczema, acne)
Breasts
FEMALES: uterus, tubes, ovaries
MALE: prostate, penis, testes, vasectomy

Other (Please Describe)
Other (please describe)

No Problem Medical Problem Had Surgery
Year(s) of Surgery
Describe
Ever had Anesthesia Complication(s)?

Yes No
Types of complications

Malignant Hyperthermia Seizure Arrhythmia Nausea Vomiting Other
Hospitalizations
Have you ever been hospitalized?

Yes No
List hospitalizations below

ASSISTIVE DEVICES

Please indicate if you currently require any assistive devices.
Do you use any assistive devices?

Yes No
Brace(s)

Knee Neck Wrist Back
Lifeline / Medical Alert Device

Yes No
Sleep Apnea Device

CPAP BIPAP
Cane-Standard

Standard cane used in left hand Standard cane used in right hand
Cane-Quad

Quad cane used in left hand Quad cane used in right hand
Contacts

Soft contact Hard Contact
Crutches

Axillary crutches (arm pit) Forearm crutches
Dentures-Complete

Complete Lower Complete Upper Complete Upper & Lower
Dentures-Partial

Partial Lower Partial Upper Partial Upper & Lower
Glasses

Glasses Bifocals Trifocals
Hearing Aid

Bilateral Left Right
Walker

Rolling Standard walker Rolling with platform
Wears Corrective Shoes

Bilateral feet Left foot Right foot
Wheelchair

Manual Electric

OBSTETRIC/ GYNECOLOGIC HISTORY FOR WOMEN
Total Number of Pregnancies (viable and nonviable) in lifetime
Total number of living children
# Full Term babies
# Premature babies
# Miscarriages (spontaneous abortions)
# Elective termination of pregnancy(s)
Age of menopause
NA/ I have not reached menopause
Age of first menstrual period
Date of last menstrual period:

Month Day Year
Date
Period Frequency
# of days
Current Contraceptive Method(s)

None Abstinence Coitus Interruptus Female Condoms Male Condoms Depo-Provera Injection Diaphragm Essure IUD-Copper (Paragard) IUD-Levonorgestrel (Mirena, Kyleena, Liletta, Skyla) Oral Contraceptive (pill) Patch Rhythm Method Ring (Nuva) Spermicides Tubal Ligation Vasectomy
FAMILY HISTORY MEDICAL ISSUES

Place a check mark (√) in the appropriate boxes to identify all illnesses/conditions which you know have occurred in your blood relatives. Check “NONE” if you are not aware of any relative having the illness/condition. Describe the illness or condition.

	Father	Mother	Brothers	Sisters	Paternal Grandmother	Paternal Grandfather	Maternal Grandmother	Maternal Grandfather	None	Describe
Immune Problems, HIV, AIDS
Alcoholism
Addiction - Drugs
Anemia
Arthritis (childhood) (JRA)
Birth Defects
Bleeding/Clotting Disorder
Crohn's or ulcerative colitis
Developmental Delay
Diabetes
Epilepsy or Convulsions
Heart Disease (before 50 years old)
High Blood Pressure (Before age 50)
Kidney Disease
Liver Disease
Mental Illness
Intellectual Disability (Mental Retardation)
Thyroid Disease

Other information about your family which you want us to know:
Are you adopted?

Yes → If known, complete the following information below about your blood relatives (include children). Exclude adoptive parents, siblings and adopted children. No → Complete the following information about your blood relatives. Exclude adoptive siblings and adopted children.
Father

Alive Deceased Unknown
Age
Cause(s) of Death
Mother

Alive Deceased Unknown
Age
Cause(s) of Death
How many children to you have?
How many siblings do you have?

Type a question

	Number Alive	Number Deceased	Approx. Age(s) at Death	Cause(s) of Death	History Unknown
Sons
Daughters
Brothers
Sisters
Paternal Grandmother
Paternal Grandfather
Maternal Grandmother
Paternal Grandfather

SOCIAL HISTORY
Marital Status?

Divorced Domestic Partner Married Significant Other Single Widowed
What is your current living arrangement?

Apartment Assisted Living Facility Car Friend’s Home Relative’s Home Group Home House Homeless-living on street Homeless-staying in shelter Nursing Home/ Long Term Care Facility Trailer
Do you live with anyone?

Yes No
Who lives with you?
Do you have pets?

Dogs Cats Other
# of Dogs
# of Cats
# of Others
Are you exposed to tobacco or marijuana smoke in your home?

Yes No
Are you exposed to tobacco or marijuana smoke at work?

Yes No
Are their guns in your home?

No Yes, locked Up Yes, Not locked up
Highest Education Level Completed?

Elementary School Grade School High School Associates Degree Bachelor's Degree Master's Degree Doctorate Degree Vocational Degree College - 1 year College - 2 years
Grade
Vocation

BARRIERS TO CARE
Please indicate if any of the following will affect your ability to receive treatment at our practice?

Education status Family responsibilities Financial Hardship Geographic location Insurance status Language Transportation Work Hours None Identified – I am not experiencing anything affecting my ability to receive treatment at CNY Family Care
Are you currently experiencing any of the following social determinants?

Difficulty accessing transportation Difficulty affording transportation Homebound (cannot leave home) Homelessness Limited access to nutritious food Uncertain access to nutritious food Unsafe housing quality None Identified – I am not experiencing any of these
Please indicate if any of the issues below are affecting your social functioning:

Absence of Social Engagement Anxiety/Depression Declining Health/Cognition Isolation Inability to maintain an adequate social life Lack of family network Lack of friend network None Identified – I am not experiencing any of these
Please indicate if you have any learning barriers:

Intellectually disabled Cognitive ability impaired Deafness-complete Hearing impaired Impaired memory Unable to read Unable to understand when you read Vision Impaired Legally Blind None Identified – I do not have any barriers which affect my ability to learn
Please indicate if you have any communication barriers:

Primary language is not English Needs a translator at medical appointments Deafness-complete Hearing impaired Needs an American Sign Language (ASL) interpreter at medical appointments Nonverbal (does not speak) Legally blind None Identified – I do not have any barriers which affect my ability to learn
Current employment status:

Employed Work w/restrictions Retired Medically retired Unemployed Disabled (cause of disability:
What is your Occupation?
Employer Name
Employer Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Are you on a special diet?

Yes No
Type of special diet:

Diabetic diet Renal diet Mechanical soft Vegan Vegetarian Other
Are you receiving any community services?

No/None Day Service Program Home Care Homemaking services (aid for cleaning, cooking, laundry) Meals on Wheels Medical Transport Services/ Assistance Occupational Therapy Physical Therapy Speech Therapy Volunteer comes into the home Other
Are you currently experiencing any abuse?

No Yes-Bullying in school Yes-Domestic Violence Yes-Emotional abuse Yes-Physical abuse Yes-Sexual abuse
Have you been abused in the past?

No history of abuse Yes-Bullied in school Yes-Domestic Violence Yes-Emotionally abused Yes-Physically abused Yes-Sexually abused

Self-Care Assessment

Place a check mark (√) in the appropriate boxes to identify if you are independent with the activity, dependent on another individual, or require assistance to perform the activity. If you are dependent on an individual, or require assistance to perform the activity, please indicate who provides you with assistance

	Independent	Dependent	Require Assistance	Indicate who helps you perform this activity
Ambulating (Walking)
Bathing
Dressing
Feeding
Grooming
Standing
Toileting
Cleaning
Cooking
Laundry
Medication Management
Money

PERSONAL HABITS
Do you currently smoke tobacco?

Yes – every day Yes – some days Former tobacco smoker (quit) Never smoked tobacco
Do you currently smoke marijuana?

Yes – marijuana every day Yes – marijuana on some days Former marijuana smoker (quit) Never smoked marijuana
What type of tobacco do you currently use?

N/A- I do not use tobacco at this time Cigarette Cigar Pipe Smokeless tobacco (chew, snuff)
# of Cigs per day
# of packs per day
What year did you start to use tobacco?
How many total years have you used tobacco?
Are you a former tobacco user?

Yes No
Tobacco Type
Amount / Frequency
When did you quit?
What year did you start?
Do you smoke an E-Cigarette (Juul, Vape)?

Never used Current E-Cig smoker Former E-Cig smoker
Have you used alcohol in the past 12 months?

Yes No
How often do you drink an alcoholic beverage?

I deny alcohol use I have never used alcohol Daily Occasionally Rarely
How many alcoholic beverages to you currently drink? Per Day
How many alcoholic beverages to you currently drink? Type
How many alcoholic beverages to you currently drink? Per Week
How many alcoholic beverages to you currently drink? Type
If you have quit using alcohol, what was your former alcoholic beverage use frequency?

N/A – (I still drink alcohol) Daily Occasionally Rarely
Have you used recreational drugs (street drugs) or prescription drugs other than those prescribed to you in the past 12 months?

No/ I deny current drug use Yes→ Specify Drug(s):
How often are you currently using recreational/street drugs or prescription drugs other than those prescribed to you?

Never Regularly Sporadically Daily Use (addiction) Yes→ Specify Drug(s):
Have you ever used IV Drugs?

Yes No
Have you ever been to rehab?

Yes No
Are you a former recreational drug (street drug) user or former user of prescription drugs other than those prescribed to you?

No/ I deny former drug use Yes→ Specify Drug(s):
How many caffeinated beverages to you currently drink? (Per Day)
How many caffeinated beverages to you currently drink? (Type)
How many caffeinated beverages to you currently drink? (Per Day)
How many caffeinated beverages to you currently drink? (Type)
Current Exercise?

No/ None Yes→ Type:
Frequency:

Regular Rare Sporadic
In an automobile how often do you use a seat belt?

Always Never Sometimes
If you ride a bike how often do you wear a helmet?

Always Never Sometimes I do not ride a bike
I have completed this Adult Intake Form to the best of my ability
Signature of Patient *

Clear
Date *

Month Day Year
Date
Other Signature (If not patient completing this form)

Clear
Date

Month Day Year
Date
Should be Empty:

ADULT NEW PATIENT HISTORY FORM

Emergency Contact

Insurance

Care Provider

ADVANCE DIRECTIVES

IMMUNIZATION HISTORY

ALLERGIES

MEDICATIONS

HEALTH MAINTENANCE HISTORY

CHILDHOOD ILLNESS

Medical Problems Review

Hospitalizations

ASSISTIVE DEVICES

OBSTETRIC/ GYNECOLOGIC HISTORY FOR WOMEN

FAMILY HISTORY MEDICAL ISSUES

SOCIAL HISTORY

BARRIERS TO CARE

Self-Care Assessment

PERSONAL HABITS

I have completed this Adult Intake Form to the best of my ability