X New Patient Record
Family Health History:
(Check)
Relative |
Age | Good | Poor | Deceased |
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Father |
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Mother |
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Brother |
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Sister |
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Spouse |
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Child |
Cause(s) of Death: ____________
If you (Me) or a member of you family, Father (Fa), Mother (M), Sibling (Si), Spouse (Sp), or Children (C), have had the following illnesses or problems. Check the box under the appropriate initials:
| Me | Fa | M | Si | Sp | C | |
Allergies |
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Asthma |
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Eczema, Rashes |
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Thyroid |
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Lung |
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Heart |
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Cholesterol |
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High Blood Pres. |
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Phlebitis |
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Stomach/Intestinal |
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Liver Diseases |
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Kidney Problems |
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Diabetes |
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Cancer |
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Anemia/blood disease |
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Epilepsy |
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Mental Illness |
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Depression |
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Suicide Attempt |
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Alcohol/Drugs |
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Arthritis |
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Osteoporosis |
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Other |
Chart No. _______
Date: _________________________
Patient Name: ________________________________ Sex: M F
Medical Condition (Please list any chronic medical illnesses or conditions.)
_______________________ ______________________
_______________________ ______________________
Current Medications Surgeries
(Prescriptions, over the counter, (please list the year)
Herbal medication)
1. ____________________ 1. ____________________
2. ____________________ 2. ____________________
3. ____________________ 3. ____________________
4. ____________________ 4. ____________________
5. ____________________ 5. ____________________
6. ____________________ 6. ____________________
Current Allergies or Sensitivities. List anything you are allergic to and
describe how it affects you.
_______________________ ______________________
_______________________ ______________________
_______________________ ______________________
Are you: ___ Single ___ Married ___ Separated ___ Divorced
Children: Girls__Boys___
Work History: Are you currently employed? □ Yes □ No
□ Homemaker □ Retired □ Disabled
Present type of work/employer: _______________________________
| Personal Habits | Always |
Occasionally |
Never |
Regular Exercise (3 - 4 times per wk) |
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Sleep Well |
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Eat Balanced Meals |
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Brush Teeth (twice daily) |
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Happy with Life |
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Feel Anxious/Nervous |
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Feel Lonely |
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Drink Alcohol |
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Use Drugs |
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Smoke/Chew Tobacco |
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| Use seat belts when riding in Automobile |