NEW PATIENT QUESTIONAIRE UTMB FAMILY HEALTH CLINIC

NAME
AGE

DATE
DATE OF BIRTH

HEIGHT

WEIGHT

ALLERGIES to Medicine or Other:

REASON FOR VISIT:

PAST MEDICAL HISTORY: If you every had any problems in the following areas please box.
Arthritis
Blood Disease
Cancer----------------- Types Heart Disease
Diabetes
Hereditary Disease Types Urinary/Kidney
Stomach/Intestine
High Blood Pressure Low Blood Pressure
Cholesterol/Lipids
Musculoskeletal
Numbness or Tingling Chronic Pain
Anxiety
Depression
Bipolar
Other Psychiatric
COPD/Emphysema Asthma
Other Lung Problem Stroke
Thyroid Problems
Severe Injury ------- Types Seizures
Glaucoma
Cataracts
Macular Degeneration
OTHER:
SURGICAL HISTORY: If you every had any of the follow please box.
Appendectomy
Tonsillectomy
Cholecystectomy (Gall Bladder)
Heart Bypass
Heart Stent
Arterial Bypass or Stent (such as in leg, etc)
Hip Replacement
Knee Replacement Other bone/joint surgery
Thyroid Surgery
Eye Surgery
Cataract Surgery ( Right/Left)
Breast Lumpectomy Mastectomy
Hysterectomy
Oophorectomy(ovaries)
Tubal Ligation
Vasectomy
Mass Removed Where Other Surgery:

,
FAMILY HISTORY: If your relative has ever had any of the follow, please box.
Maternal=M Paternal=P Grandmother=GM Grandfather=GF Aunt=A Uncle=U
Condition
Mom
Dad
Sis
Bro
MGM MGF PGM PGF MA /U
Arthritis

Asthma

Blood Disease

Cancer

Diabetes

Hereditary Dis.

Urinary Dis.

Stomach/Colon

Liver

Hypertension

Cholesterols

Musculoskeletal

Neuro/Seizures

Mental Illness

Lung Problem

Stroke

Thyroid

PA/U

NEW PATIENT QUESTIONAIRE UTMB FAMILY HEALTH CLINIC

MEDICATION USE:
For all that apply please box
Do you use Herbs/Vitamins/Supplements regularly
Yes
What Types:

No

What medications do you take daily:

Do you use any of the following regularly: For all that apply please box
Chiropractor Massage Acupuncturist Sauna Medication Yoga/Pilates
Last Mammogram
Last Colonoscopy
Last Eye Exam

Herbalist

Last PAP Smear

Last Prostate Exam
Last Cholesterol Test

SOCIAL HISTORY: For all that apply please box - THESE QUESTIONS ARE OPTIONAL
However, answering them will help your physician give you the proper medical care you deserve.
Marital Status - Are You ->
Married
How many Biological Children do you have?

Single

Divorced
Widowed
For Females How many times pregnant

What is your Occupation:

Do you smoke Tobacco now?
If no did you quit? Yes No

Yes No
When?

If yes how much a day

How long did you smoke?

Do you drink Alcohol now?

Yes No If yes how much a day
If no did you ever?
Yes No Was it ever a problem? Yes
When did you quit
How long did you drink
Do you or have you used recreational drugs?
Yes No
What Kind?

years

No

Did you serve in the? Army Navy Marines Air Force Coast Guard
Do you have service related concerns - Agent Orange, Combat related stress, etc.? Yes
Have you had a Blood Transfusion? Yes No If Yes then When?
Do you use Caffeine food products? Yes No How often a day?
What Types? Coffee Ice Tea Monster Drinks Chocolate Other
Does your Job expose you to hazards? Yes No What
Do you have hazardous hobbies (such as Sky Diving, etc.)? Yes No What
Do you have any problems sleeping? Yes No
Cant Sleep Cant Wake Up
Do you feel stressed? Yes No
at home at work other
Do you watch your diet? Yes
Describe a typical days diet

No

No

How many times a week do you eat out?

NEW PATIENT QUESTIONAIRE UTMB FAMILY HEALTH CLINIC

Where do you eat out? Fast Food Small Dinners/Cafes Large Chain Restaurants
What kind of snacks do you like to eat?
Do you eat: Watch TV, Reading a book, While Working, While Driving, All the time,
If you had a choice would you eat - Salad Fried Shrimp/Fish Grilled Shrimp/Fish Steak
Hamburger Spaghetti/Pasta French Fries Fried Chicken Grilled Chicken Fruit Bowl
Do you Exercise? Yes No Do you exercise: alone, with others, at home, at Gym
How much during the week?
. How long per session?
min What type of Exercise?
Walking Jogging Aerobics Stair stepper/treadmills Weights/Machines
Basic Pushups/Sit-ups Basketball Tennis Racquetball Swimming
Other
Do you use a Helmet when riding a bicycle or motorcycle? Yes No
Do you use Seat Belts while Driving? Yes No
Do you perform preventative self exams (such as breast or testicular)? Yes No
Do you feel you have some type of impairment or problem that prevents you from enjoying life or
participating in the activities of daily living to the fullest Yes No
Have you been exposed to any of the following:
Asbestos
Excessive Dust
Persons recently in prison
Persons with Tuberculosis
Known Hazardous Chemicals
Persons with know contagious diseases
Persons recently from third world countries
(END OPTIONAL SECTION)

Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No

REVIEW OF SYSTEMS: If you have had any of the problems listed below in the
last year please the box. If you have had any in the last month x the box.
GENERAL:
Increased Appetite
Decreased Appetite
Chills
Being Tired
Fever
Generally feeling bad
Sweats
Weakness
Weight Gain
Weight Loss

EYES:
Blurry Vision
Worsening Vision
Double Vision
Eye Discharge
Eye Dryness
Excessive Tearing
Eye Pain
Eye Itching

Loss of vision
Excessive Redness
Sensitive to Light

EARS:
Discharge
Ear Pain
Decreased Hearing
Ringing in Ears

NOSE/SINUS:
Congestion
Smelling Problems
Nose Bleeding
Facial Pain
Allergies/Hay Fever
Itching
Drainage in Throat
Runny Nose
Sneezing
MOUTH/THROAT:

Bad Breath
Bad Taste in Mouth
Bleeding Gums
Blisters in Mouth/Gums
Pain Gums/Teeth
Difficulty Swallowing
Hoarseness
Sore on Lips
Mouth Pain
Pain with Swallowing
Mass Mouth/Tongue
Sore Throat

NECK:
Pain
Swollen Glands
Restricted Movement

HEART:
Chest Pain
Chest Pain with activity

NEW PATIENT QUESTIONAIRE UTMB FAMILY HEALTH CLINIC

Irregular Pulse
Palpitations (Pounding)
Felt a Skipped Beat
Heart Racing
Fatigue with Activity
Blue Fingers

LUNGS/BREATHING:
Chest Congestion
Cough - Dry
Cough - Wet
Short of Breath Activity
Bloody Cough
Cant take deep breath
Pain with Breathing
Must sleep sitting up
Short of Breath at Rest
Wheezing

BREASTS:
Breast Feeding
Nipple Discharge
Felt a Lump
Have Bumpy Breasts
Have Breast Pain

STOMACH/INTESTINES:
Abdominal Pain

Where?_____________
Anorexia

Decreased Appetite

Increased Appetite

Belching

Bloating

Constipation

Diarrhea

Heart Burn

Problems Swallowing
Excessive Gas

Food Intolerance

Bloody/Black Vomit

Bloody Stools

Leaking Feces (Stool)

Turning Yellow

Black Stools

Mucous in Stools

Nausea

Pain with Swallowing

Vomiting

URINARY/GENITALIA:
Not Urinating
Burning with Urination
Reduced Urination

Weak Urine Stream

Discharge
Discolored Urine
Dribbling
Painful Urination
Kidney Pain
Genital Ulcers/Lesions
Blood in Urine
Difficult starting Stream
Leaking Urine
Female:
No Period
Painful Sex
Painful Periods
Frequent Periods
Very Heavy Periods
Frequent Urination
Night time Urination
Large amount of Urine
Male:
Erection Difficulty
Painful Ejaculation
Testicular Pain
Toilet Training Problem
Urgency to Urinate
Urine Color Change

BONE/MUSCLE/JOINTS:
Decreased muscle size
Upper Back Pain

Lower Back Pain

Cold hands or feet

Problems Walking

Joint Pain

Joint Stiffness

Joint Swelling

Muscle Cramps

Muscle Pain

Muscle Weakness

SKIN:
Acne
Bruise Easily
Dry Skin
Hair Loss
Hives
Itching
Turning Yellow
Skin Sores
Changes in Moles
Nail Changes
Pallor
Red Spots
Pigmentation Change

Presents of Moles
Rashes

NERVOUS SYSTEM:
Jerky Muscles (Ataxia)
Personality Changes

Convulsions/Seizures
Dizziness

Headaches

Lightheadedness

Memory Problems

Muscle Pain

Nerve Pain

Numbness

General Pain

Paralysis

Post Stroke Dysfunction

Tingling

Tremor

Vertigo (room spins)

Weakness

PSYCHOLOGIC:
Anxiety Problems

Pay Attention Problems

Behavior Changes

Behavior Problems

Confusion

Delusions

Depression

Emotionally unstable

Hallucinations

Want to Kill Someone

Anger/Aggression Issue
Insomnia (cant sleep)
Irritable

Stressed Out

Want to Kill Self

ENDOCRINE:
Neck Mass (Goiter)
Hair Loss
Cant take Cold
Cant take Heat
Thirsty all the time
Hungry all the time
Urinate all the time
Weight Increase
Weight Decrease

BLOOD PROBLEMS:
Bleeding Gums
Bleed Easily
Bruise Easily
Large Lymph Nodes

EXTRA COMMENTS: