Adult New Patient Form Name First Last Date of Birth Date of Appointment What Provider are you seeing?Dr. Mary ArenbergDr. George SchroederEmail Previous ProvidersPreferred PharmacyPast Medical HistoryPlease list year if possible.Any childhood illnesses:Past hospitalizations or surgeries:Previous Medical Problems:Previous Procedures (ex. EGD, breast biopsy, Colposcopy)Previous Imaging (ex: X-RAY, CT, MRI, EKG)Last Labs (please bring documentation or list below)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?YesNoCurrent medications (please list both prescription and non-prescription): PLEASE BRING ALL MEDICATIONS TO YOUR VISITImmunization Records (please bring documentation or list dates of vaccines you have received)Last PhysicalLast Eye ExamLast Dental ExamLast Colon Cancer Screening (age 50 and over)Females: Last Mammogram (age 50 and over)Females: Last Bone Density (age 65 and over)Females: Last PapFemales: Last Menstrual CyclePersonal HistoryMarital StatusSelect oneSingleMarriedDivorcedWidowedSeparatedYour occupation:Last year of school completed:Select one89101112GED or equivalentAssociate Degree or College CertificateBachelor DegreeMaster DegreeDoctorate Degree or PhDDaily Health MaintenanceHow many hours of exercise per week? What type?If you use tobacco what type? How much per day?How many packs per day?Select one12345If you use tobacco would you like help quitting?YesNoHave there been changes in job, family or living situation?Please list who lives with youHow many days in a typical week do you drink alcohol?How many alcohol drinks per typical week will you have?How often do you wear your seat belt? _______% of time in a vehicleNutrition IssuesHow are you doing with your nutrition?Vegetable (1/2 cup) servings per day? (goal is 3- 5)Fruit (1/2 cup) servings per day? (goal is 2 - 3)Do you eat fish every week?YesNoHow often do you drink soda, juice or sports drinks?Does your household have enough resources for a healthy diet?YesNoOsteoporosis PreventionPlease estimate how much dairy you eat per day. Milk (any kind of milk) ______ cups per dayCheese ______ ounces per dayYogurt ______ cups per dayDo you take a multivitamin daily?YesNoDo you take a Vitamin D supplement?YesNoOver the past 2 weeks:Have you felt down, depressed, or hopeless?YesNoHave you felt little interest or pleasure in doing things?YesNoFamily 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?YesNoAny additional concerns you would like to address today?