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PRESCRIPTION REQUEST
  
HEALTH HISTORY FORM
  
FINANCIALS FORM
  
RECORDS RELEASE FORM
    
NEW PATIENT INFORMATION FORM

GENERAL INFORMATION
first name:
last name:
*If you are a student, please list permanent address.
address:
city, state zip: ,
home phone:
cell phone:
work phone:
place of employment:
job title:
social security number:
date of birth:
age:
nearest relative name/phone:
emergency contact name/phone:
email address:
ok to contact by email: yes no
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INSURANCE INFORMATION
primary insurance name:
primary policy number:
primary group number:
primary policy holder:
primary policy holder relationship:
secondary insurance name:
secondary policy number:
secondary group number:
secondary policy holder:
secondary policy holder relationship:
does your primary insurance carrier
require authorization for:		 specialist
consultation
in-office test/procedures
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MEDICATIONS
Current Medications/Vitamins/Herbs(please include daily dosage):
List Medication Allergies:
no known allergies to drugs:
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MEDICAL HISTORY
Surgeries/dates:
medical history:
number of sons:
number of daughters:
# of pregnancy's in each category: full term
pre term
c-section
vaginal delivery
live births
children live at present
tubal pregnancies
miscarriages
terminations
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GYN HISTORY
age periods began:
last menstrualal period:
menses are: regular irregular normal heavy* light
*how many pads or tampons per day?
menstrual pain yes
pelvic pain yes
back pain yes
does medication help? yes
what medications work?
age at first intercourse:
total number of sexual partners to date:
currently sexually active: yes no
sexual preference: heterosexual bisexual lesbian
present method of birth control:
do you use condoms? yes no
Do you have a history of? DES Exposure
Ovarian Cysts
Pelvic Inflammatory Disease
Endometriosis
Infertility/Amenorrhea (scanty or skipped periods)
Uterine Cancer
Ovarian Cancer
Cervical Cancer
Breast Cancer
Colon Cancer
HIV Status: positive negative never tested
interested in being tested? yes no
Last Pap Smear:
It was: normal abnormal
Do you have a history of? Abnormal pap
Colposcopy
LEEP/ Cryosurgery/ Laser surgery

STD's/ Other Infections
Bacterial vaginosis
Chlamydia
Gonorrhea
Hepatitis B
Hepatitis C
Herpes Oral Genital
HPV (genital warts)
Molluscum contagiosum
Recurrent vaginal infections
Sexual Problems
Syphilis
Trichomonas
Yeast
Kidney Stones
Reoccurring Vaginal Itching/Discharge
Last mammogram:
It was: normal abnormal
Specify:
Last bone density test:
It was: normal abnormal
Specify:
Last colonoscopy:
It was: normal abnormal
Specify:
Last Fasting Blood Sugar:
Date and Result:
Last Cholesterol Test:
Date and Result:
Last Tetanus Injection:
Date and Result:
Last Flu Injection:
Date and Result:
Last TB Injection:
Date and Result:
Have you been vaccinated against
HPV with the Gardasil:
Date and Result:
Do you have a history of: BONES
Fractured Wrist Spine Hip Other
Osteopenia
Osteoporosis

DEPRESSION/EATING DISORDER
Anorexia
Bulimia
Binge Eating
Anxiety
Depression
Panic Attacks

BREAST
Breast Discharge
Breast Lumps
Breast Pain
Breast Surgery
Do you do breast self exams?

COLON
IBS
Constipation
Diarrhea
Hemorrhoids
Incontinence of Stool

URINARY TRACT
Frequent Urinary Tract Infections
Incontinence of Urine
Urgency
Prolapse/Dropped Bladder, Uterus or Vagina
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FAMILY HISTORY
siblings, biological parents, grandparents (maternal or paternal)
breast cancer:
uterine cancer:
ovarian cancer:
endometriosis:
premature menopause:
osteoporosis:
colon cancer:
thyroid cancer:
alcoholism:
high blood pressure:
heart disease:
high cholesterol:
diabetes:
Alzheimers:
blood clots:
mental disease:
sickle cell disease:
obesity:
strokes:
mental retardation:
birth defects:
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SOCIAL HISTORY
are you: retired
are you: disabled
marital status: married single
do you smoke? yes no former smoker
packs per day
do you drink caffeine? yes no
how often do you exercise? daily occasionally never
do you consume alcohol? yes no
if yes, # of drinks per day:
past alcohol intake:
do you have a history of illegal drug use? yes no
marijuana
heroin
cocaine
sleeping pills
pain pills
other
history sexual abuse: yes no
history domestic violence: yes no
Please list any problems/concerns you would like to discuss with the physician at your appointment:




739 Irving Avenue - Suite 640 Syracuse, NY 13210 Tel: 315-478-1158 - Fax: 315-478-3014

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