Adult New Patient Form Name First Last Date of Birth Date of Appointment What Provider are you seeing?Dr. Mary ArenbergDr. George SchroederEmail Past Medical HistoryPlease list year if possible.Any childhood illnesses:Past hospitalizations or surgeries:Previous Medical Problems:MedicationsCurrent medications (please list both prescription and non-prescription):Medication allergies and type of reaction:Do you have a history of Latex sensitivity or allergy?YesNoDo you or any family member have problems with anesthesia?YesNoDo you or any family member have bleeding problems?YesNoPersonal HistoryMarital StatusSelect oneSingleMarriedDivorcedWidowedSeperatedYour occupation:Last year of school completed:Select one89101112GED or equivalentAssociate Degree or College CertificateBachelor DegreeMaster DegreeDoctorate Degree or PhDDo you use tobacco?YesNoWhat age did you start?How many packs per day?Select one12345Do you use chewing tobacco?YesNoHow many days per week do you drink alcohol?How many drinks per day?How often in the past year have you had 5 or more drinks in a day?Other drug use? If yes, please explain: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 and any health problems they 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 Thyroid problems or x-ray treatment to neck or chest Breast masses, breast discharge, breast pain Breathing problems, shortness of breath, asthma, bronchitis, pneumonia, emphysema High blood pressure, rheumatic fever, chest pain, palpitations or skipped beats, heart murmur Heartburn, ulcers, gallstones, constipation, diarrhea, bloody or black bowel movements, abdominal pain Kidney or bladder infection, leaking urine, pain with urination, kidney stones Muscle pain, joint pain or swelling, broken bones, dislocations, muscle weakness Seizure, loss of coordination, tremors, speech problems, memory loss, numbness, tingling Rash, mole change, skin infections, hair loss Abnormal bleeding from any site, clotting problems, bruising easily Depression, poor sleeping, appetite problems, panic attacks, suicidal thoughts or attempts Concerns about sexuality or sexual function? Have you ever had any blood transfusions?YesNoFemales age 16 – 55: what was the date of your last menstrual period? Any additional concerns you would like to address today?