CARRBORO FAMILY MEDICINE CENTER

New Patient History Form

Name: ______________________________ Medical provider: ______________

Date: _______________________________ Chart#: ______________________

Why did you make this appointment to see us today?

Marital status:  Single  Married  Divorced  Separated  Widowed. Occupation: __________________

When was your last physical exam? __________. If you are female, when was your last PAP smear? ___________

Past Medical History

What chronic or previous medical problems have you had? Please list date of initial diagnosis below:

 High blood pressure If yes, what have your blood pressures been? _____________________

 Diabetes If yes, what have your blood sugars been? ______________________________

 Heart disease, heart surgery, or stroke _____________________________________________________

 Chronic lung, kidney, liver, or thyroid disease? List disorder and date __________________________

 Gastrointestinal problems? List disorder and date ___________________________________________

 Back problems? List disorder and date ____________________________________________________

 Mental illness? List disorders and dates ___________________________________________________

 Drug or alcohol dependency? What substances? _____________________________________________

 Do you follow any special diet (such as low cholesterol, diabetic, etc.). Describe ___________________

 Cancer If yes, list disease and date ____________________________________________________

 Fractures (broken bones)? _______________________________________________________________

 Any other chronic illness or disability? ____________________________________________________

What other medical providers do you see? List name and reason ________________________________________

_____________________________________________________________________________________________

Allergies

Are you allergic to any medications, plants, foods, or other items? Please list and state reaction ________________

Please continue on the back of this form.

 Family History

Please check the appropriate boxes if any blood relative had these diseases, list their relationship to you
(siblings, parents, grandparents, aunts, uncles), whether paternal or maternal, and the age of onset.

 Glaucoma  Osteoporosis or Hip fracture

 Diabetes  Depression
 Hypertension  Colon polyps
 Sudden Death  Colon cancer
 Stroke  Melanoma
 TIA (mini strokes)  Renal cell (kidney) cancer
 Heart attack  Prostate cancer
 Coronary artery disease, Angina  Breast cancer
 Heart bypass surgery  Cervical cancer
 Coronary angioplasty  Ovarian cancer
 Abdominal aortic aneurysm  Uterine cancers

Yes No Social History

___ ___ Do you smoke? How many packs per day? ____ Started at what age? _____ Never smoked ____
___ ___ Do you use other forms of tobacco? Which ones? ___________________
___ ___ If you use tobacco, are you ready to quit?
___ ___ Do you drink alcohol? How many drinks per day ____ or per week ____ of what ? ___________
___ ___ Do you use illicit or recreational drugs? Which ones and how often? _______________________
___ ___ Do you drink caffeine? How many drinks per day? _______________

Medications

List current medications, over-the-counter drugs, herbs, and supplements. List dose and frequency of administration:
_____________________________________________________________________________________
_____________________________________________________________________________________

Past Surgical History

Please list any past surgeries and dates:

 Appendectomy  Heart bypass/angioplasty  Other surgeries
 Breast biopsy  Eye surgery  Tonsillectomy
 Cataract removal  GYN surgery  Tubal ligation
 C-section  Hernia repairs  Vasectomy
 Cholecystectomy  Back surgery  Other hospitalizations

Diagnostic Procedures History

Have you had any diagnostic procedures in the past? (treadmill or other heart tests, x-rays or scans, upper or lower
endoscopy, etc.) Please list procedure and date _______________________________________________________

Do you have a Living Will? Health Care Power of Attorney? Would you like to discuss this today?

Is there anything else that you want to ask your medical provider today? __________________________________