Fillable Printable New Patient Consultation Form

New Patient Consultation Form

NEW PATIENT CONSULTATION FORM

Welcome to our office. Please fill out the first four pages.

Date_____________

Name________________________________________

Social Security Number_____-____-_____ Date of Birth__________ Age_____

Home Address________________________________________________________

Home phone____________________ Cell phone_________________________

Work phone____________________ Email address______________________

Occupation________________________

Emergency Contact

Name____________________ Relation__________ Phone number_______________

Family Doctor___________________ Referring Doctor______________________

Address_________________________ _______________________________

_________________________ ________________________________

Phone__________________________ _______________________________

Fax____________________________ _______________________________

Other Referral Source____________________________________________________

Main reason for today’s visit ______________________________________________

MEDICAL HISTORY

(Have you seen a doctor for any of the following illnesses?)

High blood pressure  YES  NO

Heart disease  YES  NO

High Cholesterol  YES  NO

Diabetes YES  NO

Kidney disease YES  NO

Asthma or Lung disease  YES  NO

Tuberculosis  YES  NO

Liver disease or hepatitis  YES  NO

Arthritis  YES  NO

Bleeding disorder  YES  NO

HIV  YES  NO

Cancer  YES  NO location____________________

Bowel disease  YES  NO (please circle): Crohn’s disease,

ulcerative colitis, polyps, irritable bowel syndrome,

diverticulitis, chronic constipation

Other________________________________________________________________

Have you ever been admitted to a hospital for a serious illness (such as a stroke, heart

attack, pneumonia, car accident)? YES NO

Please list:

SURGICAL HISTORY

Have you ever undergone surgery? YES NO

If yes, please list operations and dates:

Have you ever had a colonoscopy? YES NO

If yes, please list dates:

FAMILY HISTORY

Have any of your relatives had cancer? YES NO

Please list them and the type of cancer:

Have any of your relatives had Inflammatory Bowel Disease? YES NO

Please list any other significant family medical history (such as heart disease, diabetes,

stroke, bleeding disorder, etc)

SOCIAL HISTORY

Do you smoke now? YES NO How much? __________________

Have you ever smoked? YES NO

If yes, for how many years? ________ When did you quit?_______________

Do you drink alcohol? YES NO

If yes, how much? __________________ How often?___________________

Have you used recreational drugs? YES NO

If yes, which ones?_______________________________________________

When was the last time you used one/them? ___________________________

Marital Status: Single Married/Partner Widowed Divorced

Sexual orientation: Heterosexual Homosexual Bisexual Transsexual

Has anyone in your family or home ever physically or verbally hurt you? YES NO

Do you need assistance with getting around( ie cane, wheel chair, etc)? YES NO

Do you exercise? YES NO

(For women only)

Are you pregnant or breast feeding? _____________________

Date of your last menstrual period: ______________________

How many children do you have? ______________________

How were they delivered?

Did you have any injury during delivery? YES NO

ALLERGIES

Are you allergic to anything (medications, foods, latex)? YES NO

If yes, please list:

MEDICATIONS:

-Please list all medications and/or supplements you are taking now with times and

dosages:

REVIEW OF SYSTEMS

(Please check any symptoms you currently have)

Constitutional

Fever/chills/night sweats Unexplained weight loss Fatigue/weakness

Head and Neck

Headaches/migraines Dizziness/lightheadedness Change in vision

Difficulty hearing/ringing in ears Sleep apnea Sinus congestion

Cardiovascular

Chest pain/discomfort Palpitations Irregular heart beat

Heart murmur Leg/feet swelling (edema) Shortness of breath

Respiratory

Cough/wheeze Blood with coughing

Blood/lymphatics

Easy bleeding/bruising Anemia Received a blood transfusion at any time

Skin

New skin lesion Rash

Breast

Breast lump Nipple discharge

Endocrine

Cold/heat intolerance Excessive thirst

Psychiatric

Sleep problems Depression Anxiety/stress

Neurological

Numbness/tingling Memory loss Seizures

Musculoskeletal

Muscle/joint pain Back pain/injury Muscle weakness

Genitourinary

Leaking urine Nighttime urination Painful/bloody urination

Difficulty/concern with sexual function Genital sores

Gastrointestinal

Abdominal/stomach pain Nausea/vomiting

Heartburn/reflux Difficulty swallowing

Bloating Decreased appetite

Constipation Straining to move your bowels

Diarrhea Change in bowel movement/habits

Blood from the rectum Anal/rectal pain

Anal itchiness Anal swelling/lump/bumps

Stool incontinence Stool seepage/staining

PLEASE DO NOT WRITE ON THIS PAGE

HPI:

Bleeding: Weight Loss:

Pain: Abdominal Pain:

Mucus/Discharge/Pus:

Soiling:

Bowel Habits:

Constipation:

Straining: Anal receptive:

Incontinence: H/o Condyloma:

Incomplete defecation: CD4:

Tenesmus:

Physical Exam:

Vitals:

Abdomen:

DRE:

Proctoscopy/Flex Sig:

Plan: