Date of appointment: ______

Patient name: ______Date of birth: ______Age: ______

Primary care provider: ______Referring provider: ______

Reason for Visit: ______

*Nurse use only:

Preferred local pharmacy: ______Preferred mail order pharmacy: ______

Preferred laboratory for blood work: ______Preferred radiology facility: ______

HT ______Weight ______BP ______/______Pulse ______

Immunizations: Flu/When?_____ (65 or older) Pneumovax/When?_____

Fallen within the last 3 months? ______Fear of falling?______Difficulty ambulating? ______

Patient Review of Systems Please mark any condition with which you have had significant problems in the last 6 months:

Constitution Gastrointestinal Skin ___ Chills ___ Abdominal distention ___ Rash ___ Diaphoresis (Night sweats) ___ Abdominal pain ___ Color changes (Yellow skin) ___ Fatigue ___ Blood in stool ___ Fever ___ Constipation ___ Loss of appetite ___ Diarrhea Neurological ___ Weight loss ___ Nausea ___ Dizziness ___ Weight gain ___ Vomiting ___ Headaches ___ Black stool ___ Light-headedness HEENT ___ Change in bowel habits ___ Seizures ___ Eye pain ___ Difficulty swallowing ___ Weakness ___ Trouble swallowing ___ Gas/flatulence ___ Yellow eyes ___ Heartburn/indigestion ___ Bowel accidents Hematological Respiratory ___ Reflux ___ Enlarged lymph nodes (Adenopathy) ___ Chronic cough ___ Vomiting blood ___ Bruises/bleeds easily ___ Shortness of breath ___ Wheezing Psychiatric ___ Excessive snoring Genitourinary ___ Behavior problems (Depression) ___ Hoarseness ___ Pain on urination (Dysuria) ___ Nervous/anxious ___ Flank pain ___ Sleep disturbances ___ Blood in urine (Hematuria) Cardiovascular ___ Chest pain Musculoskeletal ___ Palpitations ___ Arthralgia’s (Joint pain) ___ Back Pain

-1- Patient name: ______Date of birth: ______

Immunizations: Y/N Date last received Flu Vaccine If 65 or older, Pneumococcal Vaccine

Please update any new medications or allergies since we last saw you in our office: Medications: Medication Name Dose Frequency

Medication Allergies: Name of allergen Reaction/Date of Onset

Social History

Tobacco Use: Y/N/Former Quit date: ______Packs/day: ______

Smokeless Tobacco: Y/N/Former Type: Chew/Snuff Quit date: ______

Alcohol use: Y/N/Former

Drinks per week: ____ glasses of wine ____ cans of beer ____ shots of liquor

Drug use: Y/N/Former

Types: ____ marijuana ____ methamphetamine ____ cocaine ____ IV

Other: ______

Caffeine use: Y/N/Former Amount/Day: ______Type: ______

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