New Patient Medical History Form

Social History

Smoking: � N / A � Never � Current smoker(___ packs / day) � Past smoker( quit _____ years ago)

� Vaping Alcohol: � N / A � Never � Occasional � Regularly(_____ drinks per day) Drugs: � N / A � Never � Current � Past � Type of drugs: __________ Marijuana: � N / A � Never � Current user(_____ times / day)

Family History

Obesity( check all that apply):			� Mother	� Father	� Sister	� Brother
� Grandmother		� Grandfather
Diabetes( check all that apply):			� Mother	� Father	� Sister	� Brother
� Grandmother		� Grandfather
Other( check all that apply):		� High blood pressure			� Heart disease		� High cholesterol
� High triglycerides � Stroke			� Thyroid problems		� Anxiety		� Depression
� Bipolar disorder	� Alcoholism � Liver disease				� Sleep disorder		� Pancreatitis
� Asthma	� ADHD
� Cancer( type / s): _______________________________________ Other: _______________________

Gynecologic History( Female)

Menstrual periods are: � Not Started
�Regular	�Irregular
�Heavy	�Normal	�Light
�Absent
Age menstrual periods began: _________				� N / A
History of Pregnancy: � Yes			� No	� N / A

System Review( Check all that apply)

General: � Recent weight loss	� Recent weight gain			� Increased appetite
� Decreased appetite Respiratory: � Cough	� Snoring			� Shortness of breath
Cardiovascular: � Chest pain	� Fainting			� Swelling ankles / extremities
� Palpitations Gastrointestinal:
� Abdominal pain	� Bloating		� Constipation		�Diarrhea
� Dysphagia / difficulty swallowing		� Food intolerance		� Indigestion	� Heartburn
� Nausea / vomiting		� Gas and bloating		� Blood in stools

Patient Label Page 4 of 5

Form Number: 530-206 Revision Date: 7 / 2024

New Patient Medical History Form | Page 4