Undergraduate New Patient Paperwork
Name (print): ___________________________________________ Date of Birth: __________________________
Today’s Date: __________________________
1. List all current medications (prescription strength and supplements): ________________________________________
2. Please record if you have been hospitalized or had surgeries in the past (and year occurred):
Appendectomy Orthopedic Surgery Tonsillectomy Other: ____________________________________
3. Please record any personal or family history of illnesses:
Self Family Self Family
Diabetes Kidney or Liver Disease
Heart Disease/Heart Attack Depression or Anxiety
High Blood Pressure Lung Condition (i.e. Asthma)
Cancer Other: _____________________
Cholesterol screening is advised for persons 20 years of age and older who have diabetes, heart disease, high blood
pressure, obesity (BMI >30), who smoke, have a family history of cardiovascular disease in male relatives younger than
50 or female relatives younger than 60.
If this applies to you, would you like your cholesterol checked? Yes No
4. Do you have any known allergies? ________________________________________ Yes No
5. If your B/P is greater than 135/80 you are at increased risk of Diabetes.
If this is your blood pressure would you like to be screened for Diabetes? Yes No
6. Have you smoked at least one cigarette in the past 30 days? Yes No
If yes to above, are you interested in quitting? Yes No
7. Over the past two weeks, have you felt down, depressed or hopeless? Yes No
Over the past two weeks, have you felt little interest or pleasure in doing things? Yes No
8. During the past two weeks have you had five or more (for men) or four drinks or more
(for women) containing alcohol (beer, wine or liquor) in a row, on at least one occasion? Yes No
In a typical week, do you drink on 3 or more occasions? Yes No
9. The CDC recommends all persons who have been sexually active to be tested for HIV.
Would you like an appointment for STI testing? Yes No
10. Women 21 and older are recommended to have PAP smears every 2 – 3 years.
Women 25 and younger are recommended to be tested for Gonorrhea and Chlamydia.
Would you like a Women’s Health appointment? Yes No
Patient Signature Date
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