Lfmsouth npq

Kenneth Sharp, DO
NEW PATIENT MEDICAL HISTORY AND QUESTIONNAIRE
The information on this form is part of your confidential medical record. Please be honest with your responses. Please be advised that, for identification and part of your medical record, your photograph will be taken during your first visit. Name: ____________________________________Male / Female Date of Birth: _____/_____/________ Age: _______ Address:______________________________________________ Social Security Number: ______-_____-__________ City: ________________________ State: ______ Zip: _________ Home Phone: ______________________________ EMAIL ADDRESS: _____________________________________ Cell Phone: ________________________________
EMERGENCY CONTACT:
Name: _________________________________ Relationship: _______________ Phone: _______________________ I hereby □ DO or □ DO NOT give permission to leave messages on my answering machine regarding appointment reminders, results of blood work, or results of other studies. I hereby □ DO or □ DO NOT give permission to receive email regarding appointment reminders, results of blood
work, or results of other studies.

I hereby give permission to Lehighton Family Medicine to discuss my medical issues, lab results, or any other matters
related to my health with ONLY the following persons: (maximum of two)
□ 1._________________________________ □ 2._________________________________
□ None. I expressly want my medical issues to remain completely private and not discussed with any family members.
EMPLOYER (or NAME OF SCHOOL):
ADDITIONAL HOUSEHOLD MEMBERS:
Name: ______________________________ Age: _____ ______________________________________________ Name: ______________________________ Age: _____ Name: ______________________________ Age: _____ Occupation: ____________________________________ Name: ______________________________ Age: _____ Work Phone: ___________________________________ Name: ______________________________ Age: _____ PREVIOUS PHYSICIAN or MEDICAL GROUP: _________________________________________________________
How did you find us: □ Previous Patient □ Phone Book □ Internet □ Friend: _____________________________ PREFERRED LOCAL PHARMACY: ___________________________________ City: __________________________
For long term medication, I prefer to use a mail order pharmacy: MAIL ORDER PHARMACY: _________________________________________ FAX #:_________________________
INSURANCE INFORMATION:
Primary Insurance Co: _____________________________________________________________________________ Name of Insured: _______________________________ Relationship to Patient: __________Date of Birth: __________ Secondary Insurance Co: ___________________________________________________________________________ Name of Insured: _______________________________ Relationship to Patient: __________Date of Birth: __________ Other: □ Self Pay (no insurance) □ Workman’s Compensation MEDICAL HISTORY: (Please check only those that apply to YOU.)
NOW PAST Unsure
NOW PAST Unsure
□ □ □ Congestive Heart Failure (CHF) PAST SURGICAL HISTORY: YEAR OF SURGERY:
PAST CANCER HISTORY:
□ Cancer of: __________________year:_______ □ Mastectomy of □Left or □Right breast. _______ □ Continuing with treatment at this time □ Nephrectomy of □Left or □Right kidney. _______ □ Cancer of: __________________year:_______ □ Continuing with treatment at this time □ Other surgery: _________________ . _______ □ Other surgery: _________________ . _______ SOCIAL HISTORY:
Marital status: □Single □Married □Divorced □Widowed □Under age of 17, living with parent/guardian
Living situation: □Living alone □Living with spouse □Living with children #___ □other:________________
Tobacco use: □Never smoked □Former smoker, quit ___ years ago □Currently smoking for ___ total years
Alcohol use: □None □Socially □Frequently: ___ drinks/beers per day □In active recovery
Recreational drug use: □None □Former user of. □Active user of. □Marijuana □Cocaine □Opiates
FAMILY MEDICAL HISTORY:
Mother □Living, age ____ □Deceased at age ____ due to: ______________________________________
History of: □Hypertension □Diabetes □Heart disease □Other:_____________ □Cancer:__________
Father □Living, age ____ □Deceased at age ____ due to: ______________________________________
History of: □Hypertension □Diabetes □Heart disease □Other:_____________ □Cancer:__________
Siblings: □None #____brothers, #____sisters
History of: □Hypertension □Diabetes □Heart disease □Other:_____________ □Cancer:__________
Other family history: ______________________________________________________________________
ALLERGIES:
□ NONE ~no known allergies □ Bactrim or Sulfas
□ other:______________________________ MEDICATIONS:
Please list ALL medications and doses you are currently taking including prescription medications, over-the-counter medications, and nutritional supplements. Medication
How taken
NUTRITIONAL SUPPLEMENTS:
□ Multivitamin
□ Glucosamine
□ Vitamin C
□ Echinacea
□ Vitamin E
□ Ginkgo Biloba
□ B-Complex
□ Saw Palmetto
□ Calcium
□ Valerian Root
□ Magnesium
□ Ginseng
□ Folic Acid
□ Ginger
□ Niacin
□ Feverfew
□ Selenium
□ Red Yeast Rice
□ ______________ □ ______________
□ ______________ □ ______________
IMMUNIZATIONS:
Hepatitis B series (series of 3) Date of last dose:____________________ Pneumonia Vaccine (every 5 years) Date of last dose:____________________ Influenza Vaccine (yearly) Date of last dose:____________________ Tetanus Vaccine (every 10 years) Date of last dose:____________________ Do you have a copy of your immunization record? GYNECOLOGIC HISTORY (WOMEN ONLY):
Age at onset of periods: _______ years old How many times have you:
Usual length of periods: _______ days Been pregnant:_____ Given Birth ____ Miscarried ____
Are your periods regular □ YES □ NO Are you: □Still menstruating □Menopausal □Post-menopausal
ADDITIONAL QUESTIONS:
Do you have any concerns about your alcohol consumption or substance abuse? Do you have any concerns about possible exposure to sexually transmitted diseases? Are you in a relationship in which you have been physically or sexually abused? Are you ever concerned for your safety or afraid of your partner? Do you have a living will or have you designated someone to make medical decisions for you in the Do you have a specific health concern? __________________________________________________ The information provided above is true and accurate to the best of my knowledge.
Signature:_____________________________________________________________ Date:______________________

Source: http://www.lehightondoc.com/files/LFMSouth_NPQ.pdf