Fillable PATIENT INFORMATION Name_ Home A Date o

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PATIENT INFORMATION Name_ Home A Date o

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PATIENT INFORMATION
Name_
______________________________________________________________________________________
First Middle Last
Phone Numbers: Cell_____________________ Home ___________________ Work ___________________
Home A
ddress__________________________________________ City___________________ Zip__________
Date o
f Birth ____________________ Social Security Number____________________ Sex ( ) Male ( ) Female
Marital St
atus ( ) Single ( ) Married ( ) Divorced ( ) Widowed Race_________________________________
Relig
ion ________________________ Do you have an Advanced Directive Living Will: Yes No N/A
Employer________________________________________ Occupation______________________________
……………………………………………………………………………………………..………………………………………………………..……..……..
Primary I
nsurance_____________________________ Name of Card Holder______________________________
Card Holders Date of Birth______________________ Relationship to patient ____________________________
Secon
dary Insurance_________________________Name of Card Holder__________________________
Card
Holders Date of Birth_____________________ Relationship to patient______________________
Patient Portal Available: If you want access to your PHI (personal health record) indicate your e-mail address
_____________
_________________________________________________ (Example: test@ptportal.com
)
In c
ase of an Emergency, who can we contact ____________________ Relationship______________________
Phon
e Numbers: Cell__________________________ Home______________ Work_____________________
How did you hear about our office? __________________________________________________________
Preferre
d pharmacy that you use (Name/Location/Phone number)
________________________________________________________________________________________
…………………………………………………………………………………………………………………………………………………………………………
NO ONE BUT MYSELF ( ) PLEASE CHECK IF MEDICAL CARE IS ONLY TO BE DISCUSSED WITH YOURSELF.
I AUTHORIZE THAT ALL ASPECTS OF MY MEDICAL CARE INCLUDING LAB/TEST RESULTS MAY BE
DISCUSSED WITH THE FOLLOWING PEOPLE:
Name_
______________________________ Date of Birth__________ Relationship__________________
Name_______________________________ Date of Birth__________ Relationship__________________
SIGNA
TURE OF PATIENT (PARENT/GUARDIAN)______________________________ DATE______________
click to sign
signature
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ADUL
T NEW PATIENT QUESTIONNAIRE
Name: ______________________________ Birth Date: _______________________________
Please list any illness or disease you have had in the past or currently have:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Please list any surgery you have had along with the date:
________________________________________________________________________________
________________________________________________________________________________
Please list any allergies to medications you may have along with the reaction:
________________________________________________________________________________
________________________________________________________________________________
Please list your current medications along with the dose and how often you take:
________________________________________________________________________________
________________________________________________________________________________
Pl
ease list any medical service encounters you’ve had outside of DMC Family Health Center:
________________________________________________________________________________________
________________________________________________________________
______________________
Do you use tobacco now? Yes No If yes, for how long? _____________________________
Have you used tobacco in the past? Yes No If yes, when did you quit? __________________
How much alcohol do you drink? (Please circle one)
None Minimal Moderate Heavy
(< 2 drinks on any one occasion) (< 3 drinks on any one occasion) (4 or more drinks on one occasion)
Please list any illness or disease in your immediate family:
Your biologic mother: _______________________________________________________________
Your biologic father: ________________________________________________________________
Your biologic brother: _______________________________________________________________
Your biologic sister: ________________________________________________________________
I certify that all the above information is accurate and to the best of my knowledge.
Patient Signature: ____________________________________ Date: _________________________
DMC Medical Group
REVIEW OF SYMPTOMS
NAME:
DATE:
The following questions will be helpful in determining any health problems you may have. Please indicate in the
comments section those areas you have any concerns or problems with:
Do you have any general problems with: Comments
Loss of appetite Night sweats
Fatigue Weight gain
Fever Weight loss
Do you have any problems with your skin or hair?
Dryness New lesions/lumps
Excessive sweating Itching
Hair growth/loss Rash/Skin color changes
Nail changes Changing moles
Do you have any problems with your eyes?
Color blindness Visual disturbances
Double vision Floaters/Flashers
Excessive tearing Problems with bright lights
Eye pain/redness Visual loss
Do you have any problems with your ears?
Deafness Ear infection
Decreased hearing Ear ache
Ear discharge Ringing in your ear
Do you have any problems with your nose?
Runny/itchy nose Sinus pain
Nose bleeds Post nasal drip
Frequent colds Chronic congestion
Do you have any problems with your mouth, throat, or neck?
B
leeding gums Voice changes
Hoarseness Neck mass
Oral ulcers Neck pain/stiffness
Sore throat Swollen glands
Do you have problems with your breathing/lungs?
Chronic cough Shortness of breath
Cough Coughing up blood/sputum
Decreased exercise tolerance Wheezing
Do you have any problems with your breast?
Breast mass Nipple discharge
Breast pain Nipple pain
Enlarging breast Skin changes
Do you have any problems with your heart or blood vessels?
Family history of sudden death Heart beating too fast/slow
Chest pain/pressure Palpitations
Swelling in your legs Waking up short of breath
High blood pressure Shortness of breath
Night cramps
Breathing problems if lying flat
TURN SHEET OVER – OTHER SIDE
Do you have any problems with your stomach or digestive system? Comments:
Heartburn/reflux Food intolerance
Abdominal mass Vomiting blood
Abdominal pain Jaundice
Change in bowel habits Blood in stool
Constipation/ Diarrhea Nausea/vomiting
Dysphasia (trouble swallowing) Bleeding from rectum
D
o you have problems with your legs or arms?
Uneven shoulders Joint pain
Limping Muscle twitching/atrophy
Claudicating Muscle cramps/weakness
Decrease range of motion Muscle aches
D
o you have problems with you neurologic system?
Auras Incoordination
Decrease memory Loss of consciousness
Dizzy/light headedness Seizures
Trouble speaking Syncope
Numbness/tingling Tremor
Headaches Vertigo/spinning sensation
Incontinence of urine/stool Weakness
D
o you have problems with your mood?
Anxiety Hallucinations
Change in sleep patterns Sleeping too much
Delusions Inability to concentrate
Depression Insomnia
Early Awakening Suicidal ideation
Fearfulness Homicidal Ideation
Do you have any problems with:
Appetite changes Sexual dysfunction
Cold/heat intolerance Easy bruising
Change in libido Enlarged Lymph nodes
Being overly thirsty Spontaneous bleeding
Do you have any problem with your urinary system?
Changes in urinary stream Blood in your urine
Painful urination Urination at night
Frequent urination Urinary retention
Urgent urination Difficulty starting urine stream
Women Only- Do you experience any of the following:
Irregular periods Heavy periods
No periods Painful intercourse
Painful periods Vaginal discharge/bleeding
M
en Only- Do you experience any of the following?
Urethral discharge Penile lesions
Impoten
ce
Testicular mass/pain
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Completed 17 April 2022

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