Date:Patient Name:Date Of Birth Email:
    Gender:Marital Status:(Please Check One)
    Telephone(1st call):Telephone(2nd call):
    Address:
    Referring Physician:
    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?
    Recreational
    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):Other:
    Do you do monthly self-exams? (Please check all that apply) Skin Cancer:
    Female:Breast Have you ever been trained properly for breast-self exam?
    Male: Testicles Have you ever been trained properly for testicular self-exam?
    Are you diabetic?If yes, what type:
    If yes, how is it controlled:
    Are you Claustrophobic (fearful of being in enclosed or narrow spaces):If yes, how is it controlled:
    Reproductive History:
    Female:Number of pregnanciesNumber of Children:Age at first Pregnancy:
    Did you breast feed:If yes, how many months(approximate):
    Age at first period:Age at menopause(if applicable):Age at last period:
    Hysterectomy:Ovaries in tact:If no, please explain:
    Hormone use:Sex drive:Method of birth control:
    Male:Impotence (Erectile Dysfunction)Sex Drive:
    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 Name

    Physician Office #

    Date Occurred

    Surgery / Injury / Hospitalization

    Physician Name / Hospital

    Physician Office #

    Date Occurred


    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)

    Female:

    Last mammogram:Last Bone Density scan:
    Last pap smear:Last pneumonia vaccine:
    Last colonoscopy:

    Male:

    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.

    Family Member

    Living Status

    Medical Problem

    Family Member

    Living Status

    Medical Problem

    Mother

    LivingDeceased

    Grandmother(P)

    LivingDeceased

    Father

    LivingDeceased

    Grandfather(P)

    LivingDeceased

    Children

    LivingDeceased

    Aunt(s)

    LivingDeceased

    Brother(s)

    LivingDeceased

    Uncle(s)

    LivingDeceased

    Sister(s)

    LivingDeceased

    Cousin(s)

    LivingDeceased

    Grandmother(M)

    LivingDeceased

    Other:

    LivingDeceased

    Grandfather(M)

    LivingDeceased

    Other:

    LivingDeceased

    Patient Signature:[signature Patient Signature]

    Date:

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