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New Patient Medical Form 1
Gender (select)
Race (select)
Address
Address
City
State/Province
Zip/Postal

Person to notify in case of emergency:

Do you have a Primary Physician?

Do you have health insurance?

PERSONAL HABITS:

When was the last time that you used recreational drugs (e.g. marijuana, cocaine, methamphetamine, etc.)? Please select:

LEGAL HISTORY:

Are you currently involved in a legal dispute?
Have you ever been arrested?

EDUCATION AND WORK HISTORY

Level of Education
While attending school, what grades do/did you typically earn?
Are you currently employed?
Have you ever served in the military?

CONTRACEPTION:

Current method of birth control (check all that apply):
Thank you for completing this confidential form. You will have the opportunity to discuss your answers
when you meet with your doctor.
For staff use only: Date reviewed with clinician:___________________________
All entries in __________ink made by _______________upon review with the patient

Medical History Questionnaire

Please check yes or no for
each condition listed below
Ear, Nose, Throat Disease?
Yes No
Eye Disease?
Checkboxes
Thyroid Disease / Goiter?
Checkboxes
Heart Disease?
Checkboxes
High Blood Pressure?
Checkboxes
High Cholesterol?
Checkboxes
Lung Disease?
Checkboxes
Diabetes?
Checkboxes
Liver / Gallbladder Disease?
Checkboxes
Stomach / Intestinal Disease?
Checkboxes
Kidney / Bladder Disease?
Checkboxes
Prostate Disease?
Checkboxes
Breast Disease?
Checkboxes
Uterine / Ovarian/ Cervical Disease?
Checkboxes
Epilepsy / Seizures/Stroke or TIA?
Checkboxes
Neurological Disease?
Checkboxes
Bone or Joint Disease?
Checkboxes
Skin Disease?
Checkboxes
Psychological Problems?
Checkboxes
Blood Disease?
Checkboxes
Cancer or Tumors?
Checkboxes
Current method of birth control?
Checkboxes
Other?
Checkboxes

SURGERIES or HOSPITALIZATIONS:

ALLERGIES: Please list all including environmental, food, & medication

MEDICATIONS: What over-the-counter or prescription medications, including vitamins and herbal preparations, have you taken in the last 3 months?

Cont’d?
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