Please allow 30 minutes to complete this detailed new patient form. Please fill out as thoroughly as possible and do not leave any fields blank. The information you provide here is kept private and confidential in accordance with Federal HIPPA Laws.
Give the following information for the last three times you have been hospitalized starting with the most recent (except normal pregnancies).
Include type of illness, month and year hospitalized, name of hospital, city and state.
Coffee
If yes, amount of coffee per day/week/month:
Cigarettes
If yes, amount of cigarettes per day/week/month:
Alcohol
If yes, amount of alcohol per day/week/month:
Other drugs
If yes, amount of other drugs per day/week/month:
frequent or severe headaches
back pains
neck lumps or swelling
loss of balance
dizzy spells
blackouts/fainting
wear glasses
blurry vision
eyesight worsening
see double
see halos or lights
eye pains or itching
watering eyes
earaches
hearing difficulties
ringing ears
noises in ears
dental problems
sore or bleeding gums
sore tongue
congested nose
running nose
sneezing spells
head colds
nosebleeds
sore throat
difficulty swallowing
hoarse voice
wheezing or gasping
frequent coughing
cough up phlegm
recurring indigestion
frequent belching
nausea
vomiting
pain in abdomen
bloated abdomen
constipation
loose bowels
black stools
gray or whitish stools
pain in rectum
itching rectum
blood with stools
frequent urination
involuntary urination
burning on urination
black or bloody urine
weak urine stream
difficulty starting urine
constant urge to urinate
hopeless outlook
difficulty relaxing
worry a lot
scary dreams or thoughts
feeling of desperation
shy or sensitive
dislike criticism
angered easily
annoyed by little things
family problems
problems at work
aching muscles or joints
swollen joints
back or shoulder pains
weakness in arms or legs
painful feet
trembling
numbness
leg cramps
skin problems
scalp problems
itching or burning skin
bruise easily
nervousness or anxiety
nervous with strangers
nail biting
difficulty making decisions
lack of concentration
loss of memory
lonely or depressed
frequent crying
MEN ONLY
burning or discharge
swelling on testicles
painful testicles
WOMEN ONLY
missed periods
menstrual problems
bleeding between periods
heavy bleeding
bearing down feelings
Other:
Click the check box in the appropriate columns for any illnesses that you or your relatives have had:
The information you provide here is kept private and confidential in accordance with Federal HIPPA Laws.