New Patient Form Name First Last Date of Birth MM slash DD slash YYYY Date of Appointment MM slash DD slash YYYY What Provider are you seeing? Dr. Mary Arenberg Dr. George Schroeder Courtney Hansen, APNP Email Past Medical HistoryPlease list year if possible.Any significant childhood illnesses:Past hospitalizations, surgeries or blood transfusions:Medical Problems:Current Medications (Please list both prescription and non-prescription, BRING MEDS TO APPOINTMENT.)Medication allergies and type of reaction:Do you have a history of Latex sensitivity or allergy? Yes No Do you or any family member have problems with anesthesia? Yes No Do you or any family member have bleeding problems? Yes No Personal HistoryMarital StatusSelect oneMarriedSingleDivorcedWidowOccupation: Highest level of education completed: Tobacco Use (cigarettes, vaping, chewing): Yes No If yes, at what age did you start? If yes, how many packs per day?Select one12345Are you interested in information to help quit? Yes No How many days per week do you drink alcohol? On a typical day how many drinks do you have? What is the most drinks you had on any day in the past month? Other drug use?Family HistoryPlease list any illness in your family members such as heart disease, stroke, diabetes, cancer, high blood pressure, high cholesterol, lung disease, liver or kidney disease, depression or suicide.FatherMotherBrother(s)Sister(s)Paternal GrandfatherPaternal GrandmotherMaternal GrandfatherMaternal GrandmotherPlease list your children, birth year and any health problems they may have:Please check any problems listed below that YOU have had in the LAST YEAR:Please select all that apply Fever, chills, night sweats, weight loss or gain Headaches, head injuries, concussion Eye problems, do you wear contacts or glasses? Do you have any loose or capped teeth? Dentures? Cold or allergy symptoms, nose bleeds Ear problems, hearing loss, ringing, ear pain, hearing aids? Thyroid problems or x-ray treatment to neck or chest Breast masses, breast discharge, breast pain Cough, shortness of breath, asthma, bronchitis, pneumonia, emphysema High blood pressure, chest pain, palpitations, heart murmur Heartburn, bowel changes, abdominal pain Kidney or bladder infections, leaking urine, pain with urination, kidney stones Muscle pain, joint pain or swelling, broken bones, muscle weakness Seizure, head injury, tremors, speech problems, memory loss Rash, mole change, skin infections, hair loss Bleeding problems, clotting problems, bruising easily Depression, poor sleeping, panic attacks, suicidal thoughts or attempts Concerns about sexuality or sexual function? Have you ever been emotionally or physically abused by a family member or someone important to you? Yes No Do you have adequate resources for food and shelter? Yes No FEMALES: date of your last menstrual period? Any additional concerns you would like to address today?