Cnyfamilycare - ADULT NEW PATIENT HISTORY FORM

ADULT NEW PATIENT HISTORY FORM
Today's Date

MonthDayYear
Date
Patient Name
Date of Birth

MonthDayYear
Date
SS#
Sex at Birth

MaleFemale
Current Sex

MaleFemale
Current Gender Identification

MaleFemaleTransgender MaleTransgender FemaleNon-Binary
Patient Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / 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?

PatientSpouseOther, 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

MonthDayYear
Date

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

Street Address

Street Address Line 2

CityState / Province

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

Street Address

Street Address Line 2

CityState / 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?

YesNo
Do you have a health care proxy?

YesNo
Name
Phone Number
Please enter a valid phone number.
Have you designated someone "Power of Attorney”?

YesNo
Name
Phone Number
Please enter a valid phone number.
Have you issued an order indicating "Do Not Resuscitate" (DNR)?

YesNo
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?

YesNo
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)?

YesNo
If yes, please describe
Do you have any food allergies?

YesNo
Food Allergies

Cow's MilkEggsTree NutsPeanutsShellfishWheatSoyOther 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?

YesNo
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?

NoneChickenpoxMeaslesMeningitisMumpsPertussisPoliomyelitisRheumatic FeverRubellaOther

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)?

NOAuto AccidentHead InjuryWork InjurySports InjuryOther

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 ProblemMedical ProblemHad Surgery
Year(s) of Surgery
Describe
Ever had Anesthesia Complication(s)?

YesNo
Types of complications

Malignant HyperthermiaSeizureArrhythmiaNauseaVomitingOther
Hospitalizations
Have you ever been hospitalized?

YesNo
List hospitalizations below

ASSISTIVE DEVICES

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

YesNo
Brace(s)

KneeNeckWristBack
Lifeline / Medical Alert Device

YesNo
Sleep Apnea Device

CPAPBIPAP
Cane-Standard

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

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

Soft contactHard Contact
Crutches

Axillary crutches (arm pit)Forearm crutches
Dentures-Complete

Complete LowerComplete UpperComplete Upper & Lower
Dentures-Partial

Partial LowerPartial UpperPartial Upper & Lower
Glasses

GlassesBifocalsTrifocals
Hearing Aid

BilateralLeftRight
Walker

RollingStandard walkerRolling with platform
Wears Corrective Shoes

Bilateral feetLeft footRight foot
Wheelchair

ManualElectric

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:

MonthDayYear
Date
Period Frequency
# of days
Current Contraceptive Method(s)

NoneAbstinenceCoitus InterruptusFemale CondomsMale CondomsDepo-Provera InjectionDiaphragmEssureIUD-Copper (Paragard)IUD-Levonorgestrel (Mirena, Kyleena, Liletta, Skyla)Oral Contraceptive (pill)PatchRhythm MethodRing (Nuva)SpermicidesTubal LigationVasectomy
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

AliveDeceasedUnknown
Age
Cause(s) of Death
Mother

AliveDeceasedUnknown
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?

DivorcedDomestic PartnerMarriedSignificant OtherSingleWidowed
What is your current living arrangement?

ApartmentAssisted Living FacilityCarFriend’s HomeRelative’s HomeGroup HomeHouseHomeless-living on streetHomeless-staying in shelterNursing Home/ Long Term Care FacilityTrailer
Do you live with anyone?

YesNo
Who lives with you?
Do you have pets?

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

YesNo
Are you exposed to tobacco or marijuana smoke at work?

YesNo
Are their guns in your home?

NoYes, locked UpYes, Not locked up
Highest Education Level Completed?

Elementary SchoolGrade SchoolHigh SchoolAssociates DegreeBachelor's DegreeMaster's DegreeDoctorate DegreeVocational DegreeCollege - 1 yearCollege - 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 statusFamily responsibilitiesFinancial HardshipGeographic locationInsurance statusLanguageTransportationWork HoursNone 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 transportationDifficulty affording transportationHomebound (cannot leave home)HomelessnessLimited access to nutritious foodUncertain access to nutritious foodUnsafe housing qualityNone Identified – I am not experiencing any of these
Please indicate if any of the issues below are affecting your social functioning:

Absence of Social EngagementAnxiety/DepressionDeclining Health/CognitionIsolationInability to maintain an adequate social lifeLack of family networkLack of friend networkNone Identified – I am not experiencing any of these
Please indicate if you have any learning barriers:

Intellectually disabledCognitive ability impairedDeafness-completeHearing impairedImpaired memoryUnable to readUnable to understand when you readVision ImpairedLegally BlindNone 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 EnglishNeeds a translator at medical appointmentsDeafness-completeHearing impairedNeeds an American Sign Language (ASL) interpreter at medical appointmentsNonverbal (does not speak)Legally blindNone Identified – I do not have any barriers which affect my ability to learn
Current employment status:

EmployedWork w/restrictionsRetiredMedically retiredUnemployedDisabled (cause of disability:
What is your Occupation?
Employer Name
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you on a special diet?

YesNo
Type of special diet:

Diabetic dietRenal dietMechanical softVeganVegetarianOther
Are you receiving any community services?

No/NoneDay Service ProgramHome CareHomemaking services (aid for cleaning, cooking,laundry)Meals on WheelsMedical Transport Services/ AssistanceOccupational TherapyPhysical TherapySpeech TherapyVolunteer comes into the homeOther
Are you currently experiencing any abuse?

NoYes-Bullying in schoolYes-Domestic ViolenceYes-Emotional abuseYes-Physical abuseYes-Sexual abuse
Have you been abused in the past?

No history of abuseYes-Bullied in schoolYes-Domestic ViolenceYes-Emotionally abusedYes-Physically abusedYes-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 dayYes – some daysFormer tobacco smoker (quit)Never smoked tobacco
Do you currently smoke marijuana?

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

N/A- I do not use tobacco at this timeCigaretteCigarPipeSmokeless 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?

YesNo
Tobacco Type
Amount / Frequency
When did you quit?
What year did you start?
Do you smoke an E-Cigarette (Juul, Vape)?

Never usedCurrent E-Cig smokerFormer E-Cig smoker
Have you used alcohol in the past 12 months?

YesNo
How often do you drink an alcoholic beverage?

I deny alcohol useI have never used alcoholDailyOccasionallyRarely
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)DailyOccasionallyRarely
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 useYes→ Specify Drug(s):
How often are you currently using recreational/street drugs or prescription drugs other than those prescribed to you?

NeverRegularlySporadicallyDaily Use (addiction)Yes→ Specify Drug(s):
Have you ever used IV Drugs?

YesNo
Have you ever been to rehab?

YesNo
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 useYes→ 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/ NoneYes→ Type:
Frequency:

RegularRareSporadic
In an automobile how often do you use a seat belt?

AlwaysNeverSometimes
If you ride a bike how often do you wear a helmet?

AlwaysNeverSometimesI do not ride a bike
I have completed this Adult Intake Form to the best of my ability
Signature of Patient*

Clear
Date*

MonthDayYear
Date
Other Signature (If not patient completing this form)

Clear
Date

MonthDayYear
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