New Patient and Medical History Forms « Southwest Internal Medicine

Full (Legal) Name of Patient*
Prefix First Middle Last
Preferred Name (if different than first name above)
Is the patient a minor?
- Yes, this patient is under 18 years of age
Name of Parent / Legal Guardian
Prefix First Last Suffix
Patient Marital Status*
Sex*
- Male
- Female
Patient Social Security Number

This field is required, but if you'd rather provide this information when you arrive, you may do so.
Patient Birth Date*
Month
Day
Year

Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Mailing Address (if different)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone
Mobile Phone
Email
Occupation & Employer

What is your reason for visiting us?
- Specific Illness
- To Establish Care
- Other
(Other) Why are you visiting us?
Referred by:
Which Doctor or Hospital Referred You?
How Were You Referred?
List any other family members seen by our practice
What is your preferred pharmacy:

We use this information to send your prescriptions to be filled.

Accident Information
If your visit is related to an accident, we require additional information.
Is this visit accident related?:
Please bring accident related information. i.e. - forms, date accident etc.
Date of Accident
MM slash DD slash YYYY
State Where Accident Occurred
Accident Insurance Information
Please include detailed information about the nature of the accident, insurance information from the company or other party, including claim numbers and phone numbers.

Medical Records / Privacy
I give authorization for the following individual(s) to have access to my medical records. (Additional names may be added at the time of your appointment.)
Name
Relationship
Phone

List all prescribed medications you take and frequency:
List all over the counter medications you take and frequency: (Including vitamins and inhalers)
List all known allergies to medications:

Religious Preference

Your religious preference may be relevant to your medical care. Please let your physician know if you need any special considerations.
Health Habits and Personal Safety
All questions contained in this questionnaire are optional and will be kept strictly confidential.
Exercise
Diet
Describe your dieting habits. Are you currently dieting? Are you on a physician prescribed diet?
Number of meals you eat on an average day
Sodium intake
High levels of sodium are found in snack foods, processed foods, or ready-made foods.
Fat intake
Consider the amount of saturated and unsaturated fats you consume in your diet. These primarily come from meats, butter, oils, and fried foods.
Caffeine intake
Caffeine comes from coffee, soft drinks, tablets, and/or energy drinks.
Do you use (or have you used in the past) the following:
- Alcohol
- Tobacco

Alcohol Use
Informing your health care provider of your alcohol use will help them keep you healthier.
What types of alcoholic beverages do you consume?
- Beer
- Wine
- Liquor
- Other
What other type(s) of alcohol do you consume?
About how many alcoholic drinks per week do you consume?
Please check any statements that apply:
- I am concerned about the amount I drink
- I have considered stopping drinking
- I have experienced blackouts while drinking
- I am prone to "binge" drinking

Tobacco Use
What types of tobacco products do you currently use?
- Cigarettes
- Pipes
- Chewing
- Cigars
How often and what amount of tobacco do you use? (i.e. packs per day)
What year did you begin tobacco use?
If you have quit, what year did you quit using tobacco?

Family Health History
Many medication conditions are genetic and may be inherited from parents or grandparents.
Please indicate any significant health problems experienced by your father, mother, siblings, children, or grandparents.
Consider: Stroke, Cancer, High blood pressure, diabetes, asthma, arthritis, mental illness, heart disease, autoimmune disease, birth defects, genetic disorders, etc.

Over the last 2 weeks, how often have you been bothered by any of the following problems?*

	Not at all	Several days	More than half the days	Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself or that you are a failure or have let yourself or others down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed. Or the opposite, feeling fidgety so you have trouble sitting still
9. Thoughts that you would be better off dead or of hurting yourself in some way

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New Patient and Medical History Forms