NEW PATIENT QUESTIONAIRE – UTMB FAMILY HEALTH CLINIC
NAME
AGE
DATE
DATE OF BIRTH
HEIGHT
.
WEIGHT
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ALLERGIES to Medicine or Other:
REASON FOR VISIT:
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PAST MEDICAL HISTORY: If you every had any problems in the following areas please  box.
 Arthritis
 Blood Disease
 Cancer----------------- Types Heart Disease
 Diabetes
 Hereditary Disease  Types Urinary/Kidney
 Stomach/Intestine
 High Blood Pressure  Low Blood Pressure
 Cholesterol/Lipids
 Musculoskeletal
 Numbness or Tingling  Chronic Pain
 Anxiety
 Depression
 Bipolar
 Other Psychiatric
 COPD/Emphysema  Asthma
 Other Lung Problem Stroke
 Thyroid Problems
 Severe Injury ------- Types Seizures
 Glaucoma
 Cataracts
 Macular Degeneration
 OTHER:
SURGICAL HISTORY: If you every had any of the follow please  box.
 Appendectomy
 Tonsillectomy
Cholecystectomy (Gall Bladder)
 Heart Bypass
 Heart Stent
 Arterial Bypass or Stent (such as in leg, etc)
 Hip Replacement
 Knee Replacement  Other bone/joint surgery
 Thyroid Surgery
 Eye Surgery
 Cataract Surgery ( Right/Left)
 Breast Lumpectomy  Mastectomy
 Hysterectomy
 Oophorectomy(ovaries)
 Tubal Ligation
 Vasectomy
 Mass Removed Where Other Surgery:

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FAMILY HISTORY: If your relative has ever had any of the follow, please  box.
Maternal=M Paternal=P Grandmother=GM Grandfather=GF Aunt=A Uncle=U
Condition
Mom
Dad
Sis
Bro
MGM MGF PGM PGF MA /U
Arthritis
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Asthma
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Blood Disease 
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Cancer
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Diabetes
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Hereditary Dis. 
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Urinary Dis.
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Stomach/Colon 
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Liver
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Hypertension 
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Cholesterols
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Musculoskeletal 
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Neuro/Seizures 
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Mental Illness 
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Lung Problem 
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Stroke
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Thyroid
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PA/U
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1
NEW PATIENT QUESTIONAIRE – UTMB FAMILY HEALTH CLINIC
MEDICATION USE:
For all that apply please  box
Do you use Herbs/Vitamins/Supplements regularly
 Yes
What Types:
 No
What medications do you take daily:
Do you use any of the following regularly: For all that apply please  box
 Chiropractor  Massage  Acupuncturist  Sauna  Medication  Yoga/Pilates
Last Mammogram
Last Colonoscopy
Last Eye Exam
 Herbalist
Last PAP Smear
Last Prostate Exam
Last Cholesterol Test
SOCIAL HISTORY: For all that apply please  box - THESE QUESTIONS ARE OPTIONAL
However, answering them will help your physician give you the proper medical care you deserve.
Marital Status - Are You ->
 Married
How many Biological Children do you have?
 Single
 Divorced
 Widowed
For Females– How many times pregnant
What is your Occupation:
Do you smoke Tobacco now?
If no did you quit?  Yes  No
 Yes  No
When?
If yes how much a day
How long did you smoke?
Do you drink Alcohol now?
 Yes  No If yes how much a day
If no did you ever?
 Yes  No Was it ever a problem?  Yes
When did you quit
How long did you drink
Do you or have you used recreational drugs?
 Yes  No
What Kind?
years
 No
Did you serve in the?  Army  Navy  Marines  Air Force  Coast Guard
Do you have service related concerns - Agent Orange, Combat related stress, etc.?  Yes
Have you had a Blood Transfusion?  Yes  No If Yes then When?
Do you use Caffeine food products?  Yes  No How often a day?
What Types?  Coffee  Ice Tea  Monster Drinks  Chocolate  Other
Does your Job expose you to hazards?  Yes  No What
Do you have hazardous hobbies (such as Sky Diving, etc.)?  Yes  No What
Do you have any problems sleeping?  Yes  No
 Can’t Sleep  Can’t Wake Up
Do you feel stressed?  Yes  No
 at home  at work other
Do you watch your diet?  Yes
Describe a typical day’s diet 
 No
 No
How many times a week do you eat out?
2
NEW PATIENT QUESTIONAIRE – UTMB FAMILY HEALTH CLINIC
Where do you eat out?  Fast Food  Small Dinners/Cafes  Large Chain Restaurants
What kind of snacks do you like to eat? 
Do you eat:  Watch TV,  Reading a book,  While Working,  While Driving,  All the time,
If you had a choice would you eat -  Salad  Fried Shrimp/Fish  Grilled Shrimp/Fish  Steak
 Hamburger  Spaghetti/Pasta  French Fries  Fried Chicken  Grilled Chicken  Fruit Bowl
Do you Exercise?  Yes  No Do you exercise:  alone,  with others,  at home,  at Gym
How much during the week?
. How long per session?
min What type of Exercise?
 Walking  Jogging  Aerobics Stair stepper/treadmills Weights/Machines
 Basic Pushups/Sit-ups  Basketball  Tennis  Racquetball  Swimming
 Other
Do you use a Helmet when riding a bicycle or motorcycle?  Yes  No
Do you use Seat Belts while Driving?  Yes  No
Do you perform preventative self exams (such as breast or testicular)?  Yes  No
Do you feel you have some type of impairment or problem that prevents you from enjoying life or
participating in the activities of daily living to the fullest  Yes  No
Have you been exposed to any of the following:
Asbestos
Excessive Dust
Persons recently in prison
Persons with Tuberculosis
Known Hazardous Chemicals
Persons with know contagious diseases
Persons recently from third world countries
(END OPTIONAL SECTION)
 Yes
 Yes
 Yes
 Yes
 Yes
 Yes
 Yes
 No
 No
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 No
 No
 No
REVIEW OF SYSTEMS: If you have had any of the problems listed below in the
last year please  the box. If you have had any in the last month x the box.
GENERAL:
Increased Appetite
Decreased Appetite
Chills
Being Tired
Fever
Generally feeling bad
Sweats
Weakness
Weight Gain
Weight Loss
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EYES:
Blurry Vision
Worsening Vision
Double Vision
Eye Discharge
Eye Dryness
Excessive Tearing
Eye Pain
Eye Itching
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Loss of vision
Excessive Redness
Sensitive to Light
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EARS:
Discharge
Ear Pain
Decreased Hearing
Ringing in Ears
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NOSE/SINUS:
Congestion
Smelling Problems
Nose Bleeding
Facial Pain
Allergies/Hay Fever
Itching
Drainage in Throat
Runny Nose
Sneezing
MOUTH/THROAT:
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Bad Breath
Bad Taste in Mouth
Bleeding Gums
Blisters in Mouth/Gums
Pain Gums/Teeth
Difficulty Swallowing
Hoarseness
Sore on Lips
Mouth Pain
Pain with Swallowing
Mass Mouth/Tongue
Sore Throat
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NECK:
Pain
Swollen Glands
Restricted Movement
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HEART:
Chest Pain
Chest Pain with activity
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3
NEW PATIENT QUESTIONAIRE – UTMB FAMILY HEALTH CLINIC
Irregular Pulse
Palpitations (Pounding)
Felt a Skipped Beat
Heart Racing
Fatigue with Activity
Blue Fingers
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LUNGS/BREATHING:
Chest Congestion
Cough - Dry
Cough - Wet
Short of Breath Activity
Bloody Cough
Can’t take deep breath
Pain with Breathing
Must sleep sitting up
Short of Breath at Rest
Wheezing
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BREASTS:
Breast Feeding
Nipple Discharge
Felt a Lump
Have Bumpy Breasts
Have Breast Pain
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STOMACH/INTESTINES:
Abdominal Pain
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Where?_____________
Anorexia
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Decreased Appetite
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Increased Appetite
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Belching
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Bloating
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Constipation
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Diarrhea
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Heart Burn
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Problems Swallowing 
Excessive Gas
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Food Intolerance
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Bloody/Black Vomit
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Bloody Stools
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Leaking Feces (Stool) 
Turning Yellow
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Black Stools
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Mucous in Stools
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Nausea
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Pain with Swallowing 
Vomiting
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URINARY/GENITALIA:
Not Urinating
Burning with Urination
Reduced Urination
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Weak Urine Stream
Discharge
Discolored Urine
Dribbling
Painful Urination
Kidney Pain
Genital Ulcers/Lesions
Blood in Urine
Difficult starting Stream
Leaking Urine
Female:
No Period
Painful Sex
Painful Periods
Frequent Periods
Very Heavy Periods
Frequent Urination
Night time Urination
Large amount of Urine
Male:
Erection Difficulty
Painful Ejaculation
Testicular Pain
Toilet Training Problem
Urgency to Urinate
Urine Color Change
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BONE/MUSCLE/JOINTS:
Decreased muscle size 
Upper Back Pain
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Lower Back Pain
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Cold hands or feet
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Problems Walking
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Joint Pain
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Joint Stiffness
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Joint Swelling
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Muscle Cramps
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Muscle Pain
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Muscle Weakness
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SKIN:
Acne
Bruise Easily
Dry Skin
Hair Loss
Hives
Itching
Turning Yellow
Skin Sores
Changes in Moles
Nail Changes
Pallor
Red Spots
Pigmentation Change
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Presents of Moles
Rashes
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NERVOUS SYSTEM:
Jerky Muscles (Ataxia) 
Personality Changes
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Convulsions/Seizures 
Dizziness
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Headaches
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Lightheadedness
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Memory Problems
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Muscle Pain
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Nerve Pain
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Numbness
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General Pain
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Paralysis
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Post Stroke Dysfunction 
Tingling
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Tremor
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Vertigo (room spins)
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Weakness
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PSYCHOLOGIC:
Anxiety Problems
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Pay Attention Problems 
Behavior Changes
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Behavior Problems
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Confusion
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Delusions
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Depression
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Emotionally unstable
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Hallucinations
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Want to Kill Someone 
Anger/Aggression Issue 
Insomnia (can’t sleep) 
Irritable
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Stressed Out
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Want to Kill Self
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ENDOCRINE:
Neck Mass (Goiter)
Hair Loss
Can’t take Cold
Can’t take Heat
Thirsty all the time
Hungry all the time
Urinate all the time
Weight Increase
Weight Decrease
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BLOOD PROBLEMS:
Bleeding Gums
Bleed Easily
Bruise Easily
Large Lymph Nodes
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EXTRA COMMENTS:
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