FSM-New-Patient-Intake-Form

Chief Complaint

New Patient Registration Form

Form Content

Hello, my name is Emma, and I will help you complete the questionnaire portion of your New Patient Registration Form. The information that you provide will be summarized for your physician and is needed to complete the exam. We estimate this questionnaire will take around 25 minutes to complete, If you must stop, you can return at a later time to finish. If you want me to repeat a question, just say "repeat." Are you ready? Identification: 1. What is your full name? 2. What is your date of birth (mm/dd/yyyy)? 3. What is your sex? - Male - Female - Other 4. What are your preferred pronouns? Pharmacy Information: 5. What is the name of your preferred pharmacy? 6. What is the address of your preferred pharmacy? 7. What is the phone number of your preferred pharmacy? 8. What is the fax number of your preferred pharmacy? Review of Systems: 9. Have you experienced any skin issues in the past 2 months? Yes/No (If no, move on. If yes, ask: "Please provide details.") 10. Have you experienced any issues with your head, eyes, ears, nose, or throat in the past 2 months? Yes/No (If no, move on. If yes, ask: "Please provide details.") 11. Have you experienced any lung issues in the past 2 months? Yes/No (If no, move on. If yes, ask: "Please provide details.") 12. Have you experienced any breast issues in the past 2 months? Yes/No (If no, move on. If yes, ask: "Please provide details.") 13. Have you experienced any heart issues in the past 2 months? Yes/No (If no, move on. If yes, ask: "Please provide details.") 14. Have you experienced any stomach or intestinal issues in the past 2 months? Yes/No (If no, move on. If yes, ask: "Please provide details.") 15. Have you experienced any bladder or kidney issues in the past 2 months? Yes/No (If no, move on. If yes, ask: "Please provide details.") 16. Have you experienced any muscle or bone issues in the past 2 months? Yes/No (If no, move on. If yes, ask: "Please provide details.") 17. Have you experienced any nerve system issues in the past 2 months? Yes/No (If no, move on. If yes, ask: "Please provide details.") 18. Have you experienced any mood or psychiatric illness in the past 2 months? Yes/No (If no, move on. If yes, ask: "Please provide details.") Medication: 19. What medications do you currently take on a daily basis, including dosage and frequency? Allergies: 20. Do you have any drug or serious food allergies? Yes/No (If no, move on. If yes, ask: "Please list them and the reactions they cause.") Reproductive (women only): 21. How many pregnancies or miscarriages have you had? (If not applicable, state "Not applicable.") 22. When was your last pap smear (mm/yyyy)? 23. When was your last mammogram (mm/yyyy)? Past Surgical: 24. Have you had any surgical procedures? Yes/No (If no, move on. If yes, ask: "Please list the procedures and their dates (mm/yyyy).") Health Maintenance: 25. Have you had a colonoscopy? Yes/No (If no, move on. If yes, ask: "What year?") 26. Have you had a bone density test? Yes/No (If no, move on. If yes, ask: "What year?") Social History: 27. What is your marital status? - Single - Married - Common-law - Divorced - Widowed 28. Do you have any issues getting to sleep or staying asleep? Yes/No (If no, move on. If yes, ask: "Please provide details.") 29. Do you use tobacco? Yes/No (If no, move on. If yes, ask: "How much per day?") 30. Do you use drugs? Yes/No (If no, move on. If yes, ask: "Please list the agents and any issues.") 31. Do you exercise? Yes/No (If no, move on. If yes, ask: "Please list the activities and their frequency.")