New Patient Form

Demographics

Title First Last MI Suffix Nickname Mr. Mrs. Ms. Dr. Rev.

Address:
City:		State/ZipCode	HI TX AL AK AZ AR CA CO CT DE DC FL GA ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY

Home Phone:		Work Phone:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
SSN		Email
Birthday	(mm/dd/yyyy)	Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Annulled Divorced Domestic partner Legally Separated Married Never Married Widowed	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Fusato, Grant Dr. Baum, Marvin	Misc/Guardian
Military Status	Active DutyRetired	Who can we thank for your visit today?

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev.

Address

City	State	ZipCode
	HI TX AL AK AZ AR CA CO CT DE DC FL GA ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY

Home Phone:
Work Phone:

Medical History

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PATIENT MEDICAL HISTORY

Chief Complaint:

Primary Care Physcian:	None Doesn't Remember Other
Last Eye Exam:	1 week 1 month 3 months 6 months 1 year 2 years Other
Reason For Today's Visit:	Check up Annual Other
Current Medications:		No current medications
Drug Allergies:		No known drug allergies
Over the Counter Medications:	None Asprin Acetomenophin Ibuprofen Naproxen Other
Vitamins:	None A E C Zinc Xanten Lutein Multi Centrum Centrum Silver One a day Fish Oils/Omega 3 Flaxseed Ocuvite Icaps Other

Injuries, Surgeries, Hospitalization:
Notes:
Family Medical History:	None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid Maternal Paternal Other
Pregnant or Nursing:	No Yes Unsure Other

SOCIAL HISTORY

Occupation:	Administrator Clerical Doctor EMT Firefighter Healthcare Homemaker Lawyer Military Nurse Office Police Officer Programmer Salesperson Student Teacher None Other	Hobbies:	None Astronomy Art Baseball Boating Basketball Cooking Crafts Dancing Diving Football Fishing Golf Gardening Horseback Riding Hunting Models Needlepoint Painting Photography Piano Reading Running Roller Blading Softball Sewing Skiing Soccer Swimming Tennis Video Games Woodworking Other
Smoking Status	Never smoker (<100 cigs equiv) Former smoker (no longer smokes) Current some day smoker (not daily) Light smoker (<10 cigs/day) Heavy smoker (>10 cigs/day) Smoker (current status unknown) Current every day smoker Unknown if ever smoked Other	Type:	None Chewing Tobacco Cigarettes Cigars Pipe Other	How Long:
Alcohol:	No Yes Occasionally Socially Other	Type:	None Beer Wine Hard Liquor Other	How Long:
Illegal Drugs:	No Yes Other	Type:		How Long:
Communicable Disease:	None Ebola Flu Rabies Measles Gonorrhea Syphilis Hepatitis HIV TB Other

REVIEW OF SYSTEMS

GENERAL:	None Negative Fever Heat stroke Weight loss Weight gain Unusually tired Other
EAR, NOSE, THROAT:	None Allergies Sinus Problems Chronic Cough Dry Throat / Mouth Hard of Hearing Stuffy nose Earache Cough Other
CARDIOVASCULAR:	None Vascular Disease HBP Heart Surgery Pacemaker Heart disease Other
RESPIRATORY:	None Asthma Bronchitis Emphysema COPD Shortness of breath Wheezing Congestion Other
GENITAL, KIDNEY, BLADDER:	None painful urination frequent urination impotence yellow jaundice Other
MUSCLES, BONES, JOINTS:	None joint pain stiffness swelling cramps arthritis Other
SKIN:	None pimples, warts growths rash Other
NEUROLOGICAL:	None numbness, paralysis headache seizures migraines Other
PSYCHIATRIC:	None anxiety depression insomnia Other
ENDORCRINE:	None diabetes hypothyroid hyperthoyroid Other
BLOOD/LYMPH:	None bleeding cholestrolemia anemia Other
ALLERGIC / IMMUNOLOGIC:	None sneezing swelling redness itching hives lupus Other
GASTROINTESTINAL:	None Diarrhea Constipation Ulcer Acid Reflux Hernia Other

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