Fillable Printable New Patient Consultation Form
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 YESNO
Kidney disease YES NO
Asthma or Lung disease YES NO
Tuberculosis YES NO
Liver disease or hepatitis YESNO
Arthritis YES NO
Bleeding disorder YESNO
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 murmurLeg/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/refluxDifficulty 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 ONTHIS 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:
