This is a new patient intake form.
It asks for a comprehensive medical history
Please answer to the best of your knowledge
New Patient History General Form
Fill this out prior to 1st visit with Arbor Medical
Form 1
Date:
Date of Birth:
Name:
Address:
Phone Number
(Home):
(Cell):
(Work):
(Email):
Referring Physician (if applicable):
Phone:
Primary Physician (if applicable):
Phone:
Pharmacy:
Name:
Address
Phone:
ALLERGIES:
A)
List the drug(s) to which you have an allergy and describe the particular symptoms
with each.
1)
2)
3)
4)
5)
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( Remember to include "over the counter" drugs such as aspirin, Tylenol, Motrin, eye
MEDICATIONS: drops, laxatives, and vitamins & herbal supplements. Also include creams, ointments,
and birth control preparations).
Name
A)
B)
Dose
Times Taken Per Day (or as needed)
Do you smoke/chew tobacco?
YES
1) How many years have you smoked ?
2) How many packs do you smoke each day?
If you have quit smoking, when did you quit?
PAST SURGICAL HISTORY
List all surgeries including minor and remote surgery such as skin biopsy, joint
Date
Surgery
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NO
PAST MEDICAL HISTORY
Do you have or are you being treated for any of the following illnesses? (circle)
Diabetes
Circulation Problems
Liver Problems
Seizures
Pacemaker
Bleeding Disorder
High Cholesterol
Rheumatic Fever
Cancer
Stroke
High Blood Pressure
Heart Murmur
HIV or AIDS
Heart Attack
Heart Problem
Aneurysm
Other:
FAMILY HISTORY
Relationship:
Heartburn
Hepatits
Kidney Problems
Asthma
Respiratory Problems
Defibrillator
Thyroid Problems
Ulcers
Sleep Apnea
Fibromyalgia
Does anyone in your family suffer from chronic illness?
Illness:
(Parents, siblings, kids)
Any family history of colon/breast/ovarian/other cancer? Who?
SOCIAL
What's the highest level of education you have completed?
What is your marital status?
How many children do you have?
What kind of work do you do?
Is there any chance you could be pregnant?
Yes
Do/did you drink alcohol?
Yes
If yes, how much and how often (i.e. 2 glasses wine/day)
No
No
Do you get angry when others comment about the drinking?
Are you concerned about drinking?
Do you feel guilty about drinking?
Do you ever take a morning "eye opener"?
Do/did you use recreational drugs?
Yes
No
Do you exercise on a regular basis?
Yes
No
Men
Both
If yes, please explain
Are you sexually active?
Which do you prefer as a partner
Have you ever been diagnosed with an STD?
Women
Yes
Yes
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No
No
This is a new patient intake from.
It asks for a comprehensive medical history
Please answer to the best of you knowledge
New Patient History Supplement
Dr. Patrick Alger
Fill this out prior to 1st visit with Dr. Alger
Form 2B
Date:
Name:
Date of Birth:
Where is your pain located?
Please shade the areas of your pain in the diagrams below.
When did your pain first start?
Where is your pain located?
What do you think is causing your pain?
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Did your pain begin with an injury?
If so, where did the injury occur?
Please explain how you were injured
Work
Car
Do you have a legal case pending regarding your pain?
Yes
No
Yes
No
Other (please specify)
In the following questions, please rate your pain on a scale from 0 to 10:
(0= no pain, 10= worst pain you can ever imagine)
How severe is your pain at its worst?
0 1 2 3 4 5 6 7 8 9 10
How severe is your pain at its best?
0 1 2 3 4 5 6 7 8 9 10
What is your pain level today?
0 1 2 3 4 5 6 7 8 9 10
What does your pain feel like?
Throbbing
Sharp
Stabbing
Numb
Shooting
Tingling
Other (please explain)
Tender
Pressure
Deep
Aching
Cramping
Burning
Heaviness
What is the pattern of your pain? (Please circle all that apply.)
Always present
Comes and Goes
What makes your pain worse? (Please circle all that apply.)
Sitting
Twisting
Lifting
Coughing
Bending
Driving
Sneezing
Standing
Lying Down
Bending
Walking
Sitting
Medications
Ice
Other
Does your pain make you feel (Please circle all that apply.):
Depressed
Angry
Frustrated
Lying Down
Other
What makes your pain better? (Please circle all that apply.)
Rest
Worsens as the day goes on
Helpless
Heat
Hopeless
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Please check any previous treatment you have had for your current pain
Herbal remedies:
Any benefit?
Physical or occupational therapy:
When was the last session?
How long did therapy last?
Any benefit?
Chiropractor visit:
Any benefit?
Injections:
Where?
When?
Any benefit?
Who did them?
Surgeries:
Any benefit?
Biofeedback:
Any benefit?
Accupuncture:
Any benefit?
Have you had any tests performed related to your pain? (Please circle all that apply.)
Xray
MRI
CT
Bone Scan
Blood Test
EMG
Myelogram
Please list all CURRENT pain medications you are taking along with dosage and frequency.
Please indicate if the medications help or not.
Please list all PREVIOUS pain medications you are taking along with dosage and frequency.
Please indicate if the medications help or not.
Are you currently taking blood thinner medications?
Work History
Are you currently working?
If yes, who is your current employer?
Yes
No
Yes
No
Yes
No
What is your occupation?
Are you on disability?
If yes, how long have you been disabled?
What caused you to become disabled?
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Psychosocial History
Have you ever been treated for an emotional or behavioral disorder
If yes, please explain:
Yes
No
Have you ever been treated for depression?
If yes, when?
Yes
No
Yes
No
Yes
No
Have you ever attempted suicide?
If yes, when?
Do you currently have suicidal thoughts?
Review of Systems
Please circle any of the following problems you are currently experiencing:
Constitutional:
Weight change
Weakness
Fatigue
Hearing Loss
Diziness
Ringing in Ears
Shortness of breath
Chest pain
Palpitations
Eyes, Nose, Throat:
Cardiovascular:
Gastrointestinal:
Heartburn
Diarrhea
Genitourinary:
Nausea Vomiting
Bowel Incontinence
Fever
Sore Throat
Ankle Swelling
Abdominal Pain
Bloody Stool
Constipation
Pain with Urination
Bladder Incontinence
Urgency
Joint Pain
Stiffness
Neck or back Pain
Musculoskeletal:
Skin:
Nasal Congestion
Blood in Urine
Rash
Lumps
Itching
Nail or Hair changes
Headache
Weakness
Numbness
Seizures
Neurological:
Psychological:
Nervousness
Endocrine:
Black Outs
Tension Depression
Heat or cold intolerance
Sweating
Bruising
Bleeding
Hematologic:
Memory loss
Anxiety
Hunger
Thirst
Change in urination
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ORT
Family History of Substance Abuse
1) Alcohol
2) Illegal drugs
3) Prescription drugs
Personal History of Substance Abuse
1) Alcohol
2) Illegal drugs
3) Prescription drugs
Mark if Applicable
⎕
⎕
⎕
⎕
⎕
⎕
Are you 16-45 years old?
⎕
History or Pre-adolescent sexual abuse?
⎕
Psychological Disease
1) Attention deficit/hyperactive disorder
Obsessive Compulsive disorder
Bipolar Disorder/Schizophrenia
2) Depression
⎕
⎕
OSA Screen
Snoring: Do you snore loudly (louder than talking or loud enough to be heard through closed doors?
Tired: Do you often feel tired, fatigued, or sleepy during daytime?
Observed: Has anyone observed you stop breathing during your sleep?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Blood pressure: Do you have or are you being treated for high blood pressure?
BMI: Is your BMI more than 35kg/ m ?
2
Age: Are you over 50 years old?
Neck circumference: Is your neck circumference greater than 40 cm?
Gender: Are you male?
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