Medical History - New Patient Questionnaire printable pdf download

Medical History - New Patient Questionnaire

As a new patient, you have a lot of background to share with a new physician. Use this template

when you are visiting a physician or specialist 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 TIP: 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. Is there anyone in your family with heart disease, high blood pressure, diabetes, kidney,

cancer or other medical problems?

Yes

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

Condition:

Relationship:

Condition:

Relationship:

Condition:

Relationship:

Condition:

Relationship:

Condition:

Relationship:

2. List your current physicians.

Specialty:

3. Enter the date of your last physical exam and list the physician who saw you.

Month:

Date:

Year:

Physician:

4. (Women only) Enter the date of your last OB/GYN exam and list the physician who saw

you.

Month:

Date:

Year:

Physician:

5. 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:

Medical History - New Patient Questionnaire