Date:Patient Name:Date Of Birth Email:
Gender:MaleFemaleMarital Status:(Please Check One)MarriedSingleDivorcedWidowOther
Telephone(1st call):Telephone(2nd call):
Primary Care Physician:
What is your primary language?:
Person(s) with your Medical Records Access:
Have you executed a durable Power of Attorney, Directive to Physician and/or Living Will?YesNo
Would you like additional information regarding these documents?YesNo
If you have signed one of these legal documents then please speak to the nurse regarding your decisions
and bring a copy with you to your appointment
Do you have daily transportation available:YesNo
I am currently: Working:YesNoWork Schedule is:Full-timePart-timeSick LeaveRetiredDisability
What type of work do you currently do or have done?
Do you use any of the following? (Please check all that apply)
Alcohol:YesNoWhat type?How much?How often?If quit, when?
Tobacco:YesNoWhat type?How much?How often?If quit, when?
Caffeine:YesNoWhat type?How much?How often?If quit, when?
Drugs:YesNoWhat type?How much?How often?If quit, when?
How much time do you spend exercising each week?What type of exercise?
Do you need to use any of the following?(Please check all that apply):CaneWalkerWheelchairOxygenOther:
Do you do monthly self-exams? (Please check all that apply) Skin Cancer:SkinMoleOther
Female:Breast YesNoHave you ever been trained properly for breast-self exam? YesNo
Male: Testicles YesNoHave you ever been trained properly for testicular self-exam?YesNo
Are you diabetic?YesNoIf yes, what type:
If yes, how is it controlled:DietOral MedicationInsulinOther
Are you Claustrophobic (fearful of being in enclosed or narrow spaces):YesNoIf yes, how is it controlled:
Female:Number of pregnanciesNumber of Children:Age at first Pregnancy:
Did you breast feed:YesNoIf yes, how many months(approximate):
Age at first period:Age at menopause(if applicable):Age at last period:
Hysterectomy:YesNoOvaries in tact:YesNoIf no, please explain:
Hormone use:YesNoSex drive:YesNoMethod of birth control:
Male:Impotence (Erectile Dysfunction)YesNoSex Drive:YesNo
What is your understanding as to why you are being seen today:
Additional Medical Condition History
(If additional space is needed please ask for another copy of this page)
Diagnosis / Condition
Physician Office #
Surgery / Injury / Hospitalization
Physician Name / Hospital
Please list the names of the hospital(s) or Clinic(s) where you had radiology tests in the last six months:
Preventive Health Maintenance
(Please provide dates for each or answer none)
Last mammogram:Last Bone Density scan:
Last pap smear:Last pneumonia vaccine:
Last colonoscopy:Last PSA screening:
Last prostate exam:Last pneumonia vaccine:
Is there any family history of cancer, blood disorders, cardiovascular disease, or other medical problems? If so, record below.
Patient Signature:[signature Patient Signature]