New Patient Medical History

Please complete this form prior to your first appointment

Name * First Last
Date Of Birth * / MM / DD YYYY
Gender *
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone * - (###) - ### ####
Email *
Reason For Visit *
If "Other" Please Specify
Preferred Pharmacy *

Example: "CVS on 34th and Archer Rd, Gainesville FL. #(352) 373-2507" Example: CVS Caremark, 90 day supply"
Medical History (Diagnoses) * None Hypertension High Cholesterol Diabetes Hypothyroidism GERD Depression Anxiety Other
If "Other" Please Specify:

Example: "Psoriasis since 2012"
Drug Allergies/ Reactions

Example: "Penicillin- Rash"
Current Medications/ Supplements

Example: "Cymbalta 20mg, once every morning" Example: "Baby Aspirin 81mg every day"
Refills Needed At Appointment

Example: "Cymbalta, 90 day supply to CVS CareMark"
Social History
Do You Smoke? *
Explain/ Frequency
Do You Drink Alcohol? *
Explain/ Frequency
Employment Status *
Explain/ Where & What Do You Do?
Pregnancy History
Number and Type of Deliveries

Example: "3, all C-Sections"
Last Menstrual Cycle / MM / DD YYYY
Menstrual Information Regular Irregular Menopause Hysterectomy
Married? *
Sexually Active *
Surgical History

Example: "Tonsillectomy, Shands Hospital, 2014" Example: "Right Knee Arthroscopic Surgery, Tampa General 1985"
Family Medical History
Mother

Example: Hypertension, Diabetes
Father

Example: Hypertension, Diabetes
Sibling

Example: Hypertension, Diabetes
Other

Example: Hypertension, Diabetes
Health Maintanace
Date of Most Recent Flu Vaccine / MM / DD YYYY
Date of Most Recent Pneumonia Vaccine / MM / DD YYYY
Date of Most Recent Tetanus Vaccine / MM / DD YYYY
Last PPD Test / MM / DD YYYY
Date of Most Recent Mammogram / MM / DD YYYY
Date of Most Recent Pap Smear / MM / DD YYYY
Date of Most Recent Colonoscopy / MM / DD YYYY
Date of Most Recent Bone Density Exam / MM / DD YYYY
Name and Phone Number Of Previous/ Other Current Physicians *

Example: "Dr John Smith, Cardiology, Shands"
Current Issues
Check Items That Are Currently A Problem For You * None Fatigue Headache Weakness Trouble Sleeping Muscle/ Joint Pain Memory Issues Numbness/ Tingling Sweating/ Night Sweats Weight Gain/ Loss Nausea Vomiting GI Pain Sore Throat Coughing/ Wheezing Chest Pain Shortness of Breath Sinus Issues Possible UTI Rash/ Itching Anxiety Depression Diabetes High Blood Pressure Other
If "Other" Please Specify:
Is there anything specific you would like addressed at your appointment?
Lab Results/ Past Medical Records

New Patient Medical History

New Patient Medical History

Social History

Pregnancy History

Family Medical History

Health Maintanace

Current Issues