Medical History - New Patient Questionnaire

Security Crossroads Medical Center

 A few questions..

As a new patient, you have a lot of background to share with a new doctor. Use this form when you are visiting a doctor for the first time. Fill this out to bring with you to the appointment to simplify the registration process. Keep a copy for your records so that it is available when you need to visit other doctors.

IMPORTANT: The information you entered is NOT saved to protect your privacy. Please print this page after entering the data so you don't lose your information.

  1. Please enter your name : 
         Date of Birth: 


  2. Is there anyone in your family with heart disease, high blood pressure, diabetes, kidney, cancer or other medical problems?     Yes     No

    Please list any conditions and select how the person is related to you.
    Condition:      Relationship: 
    Condition:      Relationship: 
    Condition:      Relationship: 
    Condition:      Relationship: 
    Condition:      Relationship: 

  3. List your current physicians.
        Specialty: 
        Specialty: 
        Specialty: 

  4. Enter the date of your last doctors visit/physical exam and list the physician who saw you.
    Month:      Date:      Year: 
    Physician: 

  5. (Women only) Enter the date of your last OB/GYN exam and list the physician who saw you.
    Month:      Date:      Year: 
    Physician: 

  6. List any medical conditions you have and for how long you've had the condition (first month/year diagnosed)
    Condition:      Month:      Year: 
    Condition:      Month:      Year: 
    Condition:      Month:      Year: 
    Condition:      Month:      Year: 
    Condition:      Month:      Year: 

  7. Have you ever gone to an emergency room for treatment in the last 2 years?     Yes     No
    How many times in the past year? 
    List the reason and when you made each ER visit.
    Reason:      Month:      Year: 
    Reason:      Month:      Year: 
    Reason:      Month:      Year: 

  8. Have you ever stayed in the hospital overnight during the past year?     Yes     No
    How many times in the past year? 
    List the reason and when you stayed overnight.
    Reason:      Month:      Year: 
    Reason:      Month:      Year: 
    Reason:      Month:      Year: 

  9. Have you had surgery?     Yes     No
    List the type of surgery or reason for surgery including dates.
    Reason:      Month:      Year: 
    Reason:      Month:      Year: 
    Reason:      Month:      Year: 

  10. List any allergies you have to food or medications. Tip: Only 5 lines available, so summarize.

  11. Have you ever had a SERIOUS ALLERGIC REACTION (turning red, overall swelling, difficulty breathing)?     Yes     No

  12. Do you smoke?     Yes     No
    Select which products you use, how much, and number of years used.
    Tobacco product: 
    How much: 
    Years: 

  13. Do you drink alcohol?     Yes     No
    How many of each do you drink a day?
    Beer:      Wine:      Liquor: 

  14. Do you take any recreational drugs?     Yes     No

  15. Are you taking any prescription drugs currently?     Yes     No
    List drugs, dosage, and how often you take them.
    Drug Name:      Dosage:      How often: 
    Drug Name:      Dosage:      How often: 
    Drug Name:      Dosage:      How often: 

  16. How would you describe your over all health ? Tip: Only 5 lines available, so summarize.

  17. What do you do on your own to keep you healthy ? Tip: Only 5 lines available, so summarize.

IMPORTANT: The information you entered is not saved to protect your privacy. Please print this page now so you don't lose your information.
Click here to to return to New patient page.