Medical Questionnaire: New Patient Form (Step 1 of 4)

Name:* Today's Date:

Date of birth: * / / Age: SS#: - - Please enter first three digits of your SS#. Please enter mid two digits of your SS#. Please enter last four digits of your SS#.

Home Address: Street:*

City:* State: Zip:*

Phone:* - - Work: - - Cell: - -

Email:

Problem or reason for your visit:*

Referring physician:

Primary care physician:*

Insurance Name: * Primary Subscriber?:* Yes No

Contract#:* Group#: *

Secondary Insurance Name:

Contract#: Group#:

Do you have a living will?: * Yes No

Do you have power of attorney for health care decisions?:* Yes No

SOCIAL HISTORY (check all that apply):

Marital status: Single Married Divorced Widowed

Employment/School:

Stress Issues: Work Recent Trauma Illness in Family Relationship Issues Family Issues

Comments:

Tobacco: Current Previously (year quit: )

Cigarettes Chew Tobacco Cigars Amount

Alcohol: Beer Wine Liquor How often

Caffeine: # cups/day:

Diet: Are you on a special diet? Diabetes Cardiac Celiac Sprue Lactose Free Other

Recreational Drugs: