New Patient Questionnaire New Patient Questionnaire YOUR CONTACT DETAILS Name* Email* Cell Phone Home Phone Fax Number Work Phone Address* Street Address City State / Province / Region Postal / Zip Code Date of Birth*01020304050607080910111213141516171819202122232425262728293031day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth / 20192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901year Gender*Select valueMaleFemale Marital Status*Select valueSingleMarriedDivorcedIn a RelationshipEMERGENCY CONTACT Emergency Contact Name* Emergency Contact Phone number* Relationship to Emergency Contact*PRIMARY INSURANCE Primary Insurance Carrier* Primary Insurance Phone Number* Primary Subscriber ID Number* Primary Group ID Number* Primary Insurance Carrier's Address* Street Address City State / Province / Region Postal / Zip Code Subscriber's Name (if self, write self) *FirstLast Subscriber's Date of Birth*01020304050607080910111213141516171819202122232425262728293031day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth / 20192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919year Relationship to Subscriber*SECONDARY INSURANCE Secondary Insurance Carrier Secondary Insurance Phone Number Secondary Subscriber ID Number Secondary Group ID Number Secondary Insurance Carrier's Address Street Address City State / Province / Region Postal / Zip Code Secondary Subscriber's Name (if self, write self)FirstLast Secondary Subscriber's Date of Birth01020304050607080910111213141516171819202122232425262728293031day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth / 20192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919year Secondary Relationship to SubscriberPHARMACY INFORMATION Pharmacy* Pharmacy Phone Number* Pharmacy Address* Street Address City State / Province / Region Postal / Zip Code Who has been your primary doctor?*FirstLast Primary Doctor Phone Other doctors participating in your care (i.e. cardiologist, endocrinologist): 1-Name or Specialty 1-Phone 2-Name or Specialty 2-Phone 3-Name or Specialty 3-Phone 4-Name or Specialty 4-Phone Whom may we thank for this referral?Please list up to three problems you believe are the most important medical or personal issues that you would like to address: Item 1* Item 2 Item 3Please list up to three goals you have for your health: Goal 1* Goal 2 Goal 3How would you rate your physical and functional health at this time? How would you rate your physical and functional health at this time?*ExcellentGoodMildly ImpairedModerately ImpairedSeverely ImpairedCompletely ImpairedUnable to SayOtherMedications – Please gather all your prescription and non-prescription medicines and supplements (include eye drops, nasal sprays, ointments for your skin, aspirin, laxatives and vitamins) and bring them with you to your appointment. List everything that you take at this time. 1.) Medication/Vitamin 1.) Dose/Strength 1.) Frequency 2.) Medication/Vitamin 2.) Dose/Strength 2.) Frequency 3.) Medication/Vitamin 3.) Dose/Strength 3.) Frequency 4.) Medication/Vitamin 4.) Dose/Strength 4.) Frequency 5.) Medication/Vitamin 5.) Dose/Strength 5.) Frequency 6.) Medication/Vitamin 6.) Dose/Strength 6.) Frequency 7.) Medication/Vitamin 7.) Dose/Strength 7.) Frequency 8.) Medication/Vitamin 8.) Dose/Strength 8.) Frequency 9.) Medication/Vitamin 9.) Dose/Strength 9.) Frequency 10.) Medication/Vitamin 10.) Dose/Strength 10.) Frequency Do you have any drug, food or other allergies?*YesNo If so, please list the drug, food or other allergy and the type of reaction:Please put a check next to all medical conditions that you have been told that you have by a health professional. Do not list symptoms here. Eye and Ear Diseases*NoneCataractsGlaucomaMacular DegenerationHearing Loss Hearing Aid Other (Enter Description) Heart Conditions*NoneHigh Blood PressureHigh CholesterolAnginaCoronary Artery DiseaseHeart AttackAtrial FibrillationOther Irregular Heart RhythmOther (Enter Description) Lung Diseases*NoneAsthmaBronchitisEmphysema COPDPneumoniaBronchiectasisTuberculosisOther (Enter Description) Bone and Joint Conditions*NoneOsteoarthritisRheumatoid ArthritisOsteoporosisFracturesGoutPaget’s DiseaseOther (Enter Description) Endocrine Diseases*NoneThyroid over active (high)Thyroid under active (low)DiabetesAutoimmune DiseaseOther (Enter Description) Blood Disorders and Cancer*NoneAnemiaThalassemiaLow PlateletsVaricose VeinsBlood ClotsLeukemiaLymphomaBreast CancerUterine CancerOvarian CancerProstate CancerColon CancerOther (Enter Description) Gastrointestinal (Stomach and Intestinal) Disease*NoneUlcersInternal BleedingRefluxHeartburnHiatal HerniaDiverticulosisCeliacLiver Disease (Cirrhosis or Hepatitis)Gallbladder DiseasePolypsHemorrhoidsOther (Enter Description) Kidney and Urinary Tract Conditions*NoneFrequent bladder or kidney infectionsKidney DiseaseProstate DiseaseOther (Enter Description) Nervous System or Neurologic Diseases*NoneNeuropathyStrokeDementia/Alzheimer’s DiseaseParkinson’s DiseaseEpilepsy/SiezuresNervous BreakdownOther (Enter Description) Skin Conditions*NoneAcneMolesEczemaHivesVitiligoPsoriasisRosaceaOther (Enter Description) Other Health Problems*NoneAlcoholismChicken PoxShinglesADDDepressionAnxietyBipolar OCDAddiction ProblemOther (Enter Description) Have you ever had a major injury or broken bone?* List past surgeries with dates Other Hospitalizations with Dates Have you ever had a blood transfusion?*YesNo If yes, list reason and datesFill in the following as best as you can. If alive, supply current health info. If deceased, list age and cause of death. Mother Father Sister(s) Brother(s) Aunt(s) Uncle(s) Maternal Grandmother Paternal Grandmother Maternal Grandfather Paternal Grandfather Other Have any members of your family had any of the following conditions? Check all that apply. NoneCancerHeart DiseaseHypertensionStrokeDiabetesThyroid diseaseDementia/Alzheimer’s DiseaseDepressionAddictionEating DisordersOther mental illnessOther (Enter Description) Where were you born?* What is your marital status?* With whom do you live?* If you have children, how many? * Grandchildren? Great-Grandchildren? Does Dr. Schaer/Dr. Pantelick have permission to speak with any family members if it becomes urgently necessary? *YesNo Specific Wishes How much school did you complete?* What was your field of study? Current Occupation* Occupation FrequencyFull-TimePart-TimeRetired Have you ever been exposed to any chemical/toxins/asbestos?*YesNo If yes, please describe: Do you/have you travelled to other countries? *YesNo If yes, which countries and when? Have you taken antibiotics?*YesNo If yes, what for and when? Eestimates are fine. Have you EVER smoked cigarettes? *YesNo If you answered no, how old were you when you started smoking? If you answered yes, are you smoking now? YesNo How many packs a day? How old were you when you quit? How much do you smoke now? What else have you smoked? (i.e. pipe, cigar, cloves) Have you ever chewed tobacco? YesNo
