Data Form for New Patients

We would appreciate it if you could fill out this form as much as possible. Doing so would expedite your visits with us and help ensure we have correct and complete information. Please use a new line for each entry of an item.

First name:
 Middle name:
 Last name:
Date of birth:
(e.g. 15 Dec 1950) 		Sex: male female Occupation:
(e.g. part-time tech college student, part-time cashier)
Chronic medical problems:
(e.g. diabetes type 2 since 2001)
Operations:
(e.g. appendectomy 2001)
Medications:
(e.g. metformin 1000mg twice daily)
Allergies:
(e.g. penicillin: rash)
Family Hx:
(e.g. father: colon cancer; heart attack age 50)
Co-habitants:
i.e. Who lives at home with you? (e.g. husband, 3 children [5 mos, 2 yrs, 6 yrs])
Smoking: never quit yes

If "yes", how much do you smoke and for how long?
(e.g. 1 pack a day for 20 years)

Alcohol: none yes

If "yes", how much do you drink and for how long?
(e.g. 1 six-pack of beer each weekend for 10 years)

Street drugs: none yes

If "yes", what do you use and for how long?
(e.g. 1 joint of marijuana a day for 15 years)


Address:

 Home phone:

Work phone:

E-mail: