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New Patient History Forms
 
 

NOVA ABC Medical History Form

Name: ________________________________ Age: ___________________ Sex:   M   F (circle one)

Family Physician: ______________________ Phone: ___________________________

Present Status:

1. Are you in good health at the present time to the best of your knowledge?  Y   N

2. Are you under a doctor’s care at the present time?  Y   N

If yes, for what? ________________________________________

3. Are you taking any medications at the present time?  Y   N

What: ______________________ Dosage: ___________________

What: ______________________ Dosage: ___________________

4. Any allergies to any medications? Y N

What: _________________________________________________

5. History of high blood pressure?   Y   N

6. History of pre-diabetes or diabetes?   Y   N

At what age? ___________________________________________

7. History of heart attack or chest pain?   Y   N

8. History of swelling feet? Y N

9. History of frequent headaches? Y N

Migraines? Y___ N ___ Medications for headaches: __________

10. History of sleep apnea? Y___ N___ Have you ever had a sleep study? Result:_________

Do you snore? Y___ N___ Have you been told you quit breathing while sleeping? Y___ N___

Do you fall asleep while driving, riding in a car >30 min, reading, or watching TV?

Describe __________________________________________________________________

11. History of constipation (difficulty in bowel movement)? Y N

12. History of glaucoma? Y N

13. Gynecologic history:

Pregnancies: Number: _________Dates: ____________________

Is there any chance of pregnancy now? Y___ N___

Natural delivery or C-Section (specify): _____________________

Complications of pregnancy (e. g. gestational diabetes, preeclampsia, eclampsia, etc.)

Describe: __________________________________________________

Menstrual: Onset Age: _____ Regular: Y___ N___

If periods are not regular (not regular, excessively heavy, etc.), please

describe_____________________________

Have you ever been diagnosed with polycystic ovary syndrome? Y___ N___

Pain associated: Y___ N___ Last menstrual period: ___________

Hormone Replacement Therapy: Y N

What: __________________________________________

Birth Control Pills: Y N

Type: __________________________________________

Last Checkup:__________________________________________

14. Serious Injuries: Y N

Specify: _______________________________________________

15. Any surgery: Y N

Specify: _________________________________ Date: _________

Specify: _________________________________ Date: _________

16. Family History:

Age Health Disease Cause of Death Overweight?

Father: ________________________________________________________________________

Mother: _______________________________________________________________________

Brothers: ______________________________________________________________________

Sisters: ________________________________________________________________________

 

Has any blood relative ever had any of the following:

Glaucoma: Y N Who: ______________________________

Asthma: Y N Who: ______________________________

Epilepsy: Y N Who: ______________________________

High Blood Pressure Y N Who: ______________________________

Kidney disease: Y N Who: ______________________________

Diabetes: Y N Who: ______________________________

Tuberculosis: Y N Who: ______________________________

Psychiatric Disorder Y N Who: ______________________________

Heart disease/stroke Y N Who: ______________________________

Past Medical History: (check all that apply)

Polio Measles Tonsillitis

Jaundice Mumps Pleurisy

Kidneys Scarlet Fever Liver Disease

Lung Disease Whopping Cough Chicken Pox

Rheumatic Fever Bleeding Disorder Nervous breakdown

Ulcers Gout Thyroid Disease

Anemia Heart valve disorder Heart Disease

Tuberculosis Gallbladder disorder Psychiatric illness

Drug Abuse Eating disorder Alcohol Abuse

Pneumonia Malaria Typhoid Fever

Cholera Cancer Blood transfusion

Arthritis Osteoporosis Other: ________

Nutrition Evaluation:

1. Present weight: Height (no shoes): Desired weight:

2. In what time frame would you like to be at your desired weight? ________________

3. Birth Weight: Weight at 20 years of age: Weight one year ago: __

4. What is the main reason for your decision to lose weight? ______________________

5. When did you begin gaining excess weight? (Give reasons, if known); ___________

_______________________________________________________________________

6. What has been your maximum lifetime weight (non-pregnant) and when?

________________________________________________________________________

7. Previous diets you have followed: Give dates and results of your weight loss:

____________________________

____________________________

____________________________

8. Is your spouse, fiancée or partner overweight? Y N

By how much is he or she overweight?

9. How often do you eat out?

10. What restaurants do you frequent?

11. How often do you eat “fast foods”?

12. Who plans meals? Cooks? Shops?

13. Do you use a shopping list? Y N

14. What time of the day and what day do you shop for groceries?

15. Food Allergies (list):

16. Food dislikes (list):

17. Foods you crave:

18. Any specific time of the day or month do you crave food?

19. Do you drink coffee or tea? Y N How much daily?

20. Do you drink soft drinks? Y N How many daily? Diet or regular?

21. Do you drink alcohol? Y N How much?

22. Do you use a sugar substitute? Y N

23. Do you awaken hungry during the night? Y N

What do you eat?

Have you ever found evidence of night time eating without your knowledge?____________

24. What are your worst food habits?

Do you “binge eat? Y___ N ___ How often? ____________

25. Have you ever induced vomiting or taken laxatives or diuretics for weight loss?

Have you ever been diagnosed with bulimia? Y____ N___

Have you ever been diagnosed with Anorexia Nervosa? Y___ N___

26. Snack Habits: What?

When?

How Much?

27. When you are under a stressful situation at work or family related, do you tend to reach more?

Explain:

28. Do you think are currently undergoing a stressful situation or an emotional upset?

Explain:

29. Smoking habits: (answer only one)

____ You have never smoked cigarettes, cigars or a pipe

____ You quit smoking ___ years ago and have not smoked since

____ You have quit smoking cigarettes at least one year ago and now smoke cigars or a pipe without

inhaling smoke

____ You smoke 20 cigarettes per day (1 pack)

____ You smoke 30 cigarettes per day (1 and ½ packs)

____ You smoke 40 cigarettes per day (2 packs)

30. Typical Breakfast Typical Lunch Typical Dinner

Time eaten: Time eaten: Time eaten:

Where: Where: Where:

With whom: With whom: With whom:

31. Describe your usual energy level:

32. Activity Level: (answer only one)

____ Inactive—not regular physical activity with a sit-down job.

____ Light activity—no organized physical activity during leisure time.

____ Moderate activity—occasionally involved in activities such as weekend golf, tennis, jogging,

          swimming or cycling.

____ Heavy activity—consistent lifting, stair climbing heavy construction, etc. or regular

____ Vigorous activity—participation in extensive physical exercises for at least 60 minutes per

session 4 times per week.

33. Behavior style: (answer only one)

____ You are always calm and easy going.

____ You are usually calm and easy going.

____ You are sometimes calm with frequent impatience.

____ You are seldom calm and persistently driving for advancement.

____ You are hard-driving and can never relax.

Current Symptoms (please circle if present)

General:

Appetite Increase Appetite Decrease Chills Fatigue Fever Sweats

Eyes- Last check up (Date or how long ago)__________

Blurred vision Double vision Cataracts Eye pain Redness Glaucoma Recent change in vision

Ears

Decreased hearing Pain Ringing Use of hearing device

Nose

Allergies Congestion Obstruction

Throat

Enlarged tonsils Snoring Sore throat Trouble swallowing

Cardiovascular

Chest pain or pressure Fainting or black out spells Heart murmur

Palpitations(racing heart or skipped beats) Shortness of breath Trouble lying flat

Swelling in legs or feet

Respiratory (Lungs)

Congestion Cough Rattling or wheezing

Stomach and gastrointestinal Last colonoscopy (year) ______

Bloody stools Cramps Constipation Diarrhea Heartburn or reflux Nausea Pain Vomiting

Muscles, joints, and bones

Arthritis Back pain Joint pain or stiffness (where)______________________________________

Morning stiffness Muscle pain Muscle weakness

Skin

Acne Dry or scaly Itching Lump, nodule, or mole (where)______________ Nail changes

Rash (where)________________

Breast Last mammogram___________

Discharge Lump Pain Rash or redness

Neurologic

Forgetfulness Numbness Weakness

Psychiatric

Anxiety Crying spells Depression Insomnia Panic attacks Rage or temper problems

Suicidal feelings

Hormones

Excessive hunger Excessive thirst Decreased libido Hoarseness Recent hair growth

Hormones (Female) Last female exam ________

Change in periods

Blood and circulation

Clotting problems Easy bruising

Allergy and immune

Frequent infection Seasonal allergies

Please describe your general health goals and improvements you with to make:

What kind of dietary approach do you feel is best for you? (Circle one, feel free to leave blank, we’ll go over

this): ALL FOOD, PARTIAL MEAL REPLACEMENT (USE A MEAL REPLACEMENT

FOR ONE OR MEALS DAILY, OR TOTAL MEAL REPLACEMENT (Very low calorie “protein

sparing fast for quicker weight loss).

Do you feel you will need medication for appetite suppression?

Do you want vitamin B12 shots? (These are not given routinely, but many patients request them) Y N

This information will assist us in assessing your particular problem areas and establishing your

medical management. Thank you for your time and patience in completing this form.