New Patient Questionnaire
Name
First Name
Last Name
Age
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Male
Female
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Company Name
1
Current Medical Status
Current Health Status
Rows
Value
Remarks
Blood Pressure
Heart Rate
Respiratory Rate
Temperature
Height (cm)
Weight (lbs)
Important Health Questions
Rows
Yes
No
Remarks
Are you pregnant? *woman
2
3
Are you smoking?
4
5
Are you drinking alcohol?
6
7
Are you taking any harmful substance?
8
9
Are you on a special diet?
10
11
Do you have any allergies?
12
13
Are you currently taking any medications (supplements, vitamins, contraceptives, etc.)? If yes, please list them below and the reason why you're taking it.
Did you undergo any surgery in the past? If yes, please indicate the name of the procedure.
Have you been hospitalized? If yes, please provide the date and the reason why you were admitted.
Family History: Please select if your family has a history of the conditions listed below:
Asthma
Diabetes
Heart Disease
Breast Cancer
Prostate Caner
Ovarian Cancer
Hypertension
Metal Illness
Other
Immunization: Please provide the vaccine that you already received.
Assessment
Review of Body Systems
Rows
Normal
Abnormal
Remarks
Sensory
14
15
Cardiovascular
16
17
Respiratory
18
19
Digestive
20
21
Skin/Integumentary
22
23
Bone
24
25
Spinal Cord
26
27
Neurological
28
29
Joints
30
31
Created by
Name
First Name
Last Name
Position/ Title
Signature
Date Signed
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Print Form
Submit
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