BSA New Patient Form: Medical History

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* 1. Name

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* 2. Date of Birth

Date

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* 3. Section 5 - Drug Allergies

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* 4. Section 5 - Current Medications

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* 5. Section 5 - Surgeries/Hospitalizations (please list the dates and procedure or diagnosis)

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* 6. Section 5 - Past Medical Issues

Allergies

Anemia

Arthritis

Asthma

Bronchitis

Cancer

Diabetes

Ear Infection

Gout

Heart Murmur

Hepatitis/Jaundice

Herpes

High Blood Pressure

Kidney Stones

Mental Illness

Osteoporosis

Pneumonia

Prostate Issues

Psoriasis

Stomach ulcers

Stroke

Thyroid Problems

Urine Infections

Venereal or Sexually Transmitted Infections

Chicken pox

Measles

Scarlett Fever

Polio

Rubella

Diphtheria

Mumps

Rheumatic Fever

Tuberculosis

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* 7. Section 5 - Pregnant

Yes

Planning

Not Applicable

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* 8. Section 5 - Date of Last Period

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* 9. Section 5 - Number of Pregnancies

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* 10. Section 5 - Number of Abortions

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* 11. Section 5 - Number of Miscarriages

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* 12. Section 5 - Number of Live births

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* 13. Section 5 - Birth Control Method

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* 14. Section 5 - Date of Last Pap Smear

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* 15. Section 5 - Date of Last Mammogram

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* 16. Section 5 - Date of Last Tetanus Shot

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* 17. Section 5 - Date of Last Flu Shot

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* 18. Section 5 - Date of Last Pneumonia Shot

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* 19. Section 5 - Date of Last Cholesterol Test

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* 20. Section 5 - Date of Last Stool/Rectal Test

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* 21. Section 5 - Date of Last TB Skin Test

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* 22. Section 5 - Do you drink alcohol?

Yes

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* 23. Section 5 - Alcohol - How often and how much at a time?

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* 24. Section 5 - Do you smoke?

Yes

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* 25. Section 5 - How often and how long have you been smoking?

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* 26. Section 5 - Do you use illegal drugs?

Yes

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* 27. Section 5 - Illegal drugs - How often and how much at a time?

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* 28. Section 5 - Family History

Alcoholism

Asthma

Cancer

Diabetes

Seizures

Glaucoma

Heart Disease

High Blood Pressure

Kidney Disease

Mental Illness

Migraines

Osteoporosis

Stroke

Thyroid Problems

Other

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* 29. Section 5 - Current or Recent Symptoms

Black Stool

Bleeding

Diarrhea or Constipation

Dizziness

Ear Ringing

Fatigue

Feeling Nervous or Sad

Hair Loss

Headaches

Heartburn

Hemorrhoids

Hernia

Loss of Appetite

Memory Loss

Nausea or Vomiting

Pain

Rash/Itching

Vision Loss

Weight Loss

Other

BSA New Patient Form: Medical History

Question Title

* 1. Name

Question Title

* 2. Date of Birth

Question Title

* 3. Section 5 - Drug Allergies

Question Title

* 4. Section 5 - Current Medications

Question Title

* 5. Section 5 - Surgeries/Hospitalizations (please list the dates and procedure or diagnosis)

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* 6. Section 5 - Past Medical Issues

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* 7. Section 5 - Pregnant

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* 8. Section 5 - Date of Last Period

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* 9. Section 5 - Number of Pregnancies

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* 10. Section 5 - Number of Abortions

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* 11. Section 5 - Number of Miscarriages

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* 12. Section 5 - Number of Live births

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* 13. Section 5 - Birth Control Method

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* 14. Section 5 - Date of Last Pap Smear

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* 15. Section 5 - Date of Last Mammogram

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* 16. Section 5 - Date of Last Tetanus Shot

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* 17. Section 5 - Date of Last Flu Shot

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* 18. Section 5 - Date of Last Pneumonia Shot

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* 19. Section 5 - Date of Last Cholesterol Test

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* 20. Section 5 - Date of Last Stool/Rectal Test

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* 21. Section 5 - Date of Last TB Skin Test

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* 22. Section 5 - Do you drink alcohol?

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* 23. Section 5 - Alcohol - How often and how much at a time?

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* 24. Section 5 - Do you smoke?

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* 25. Section 5 - How often and how long have you been smoking?

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* 26. Section 5 - Do you use illegal drugs?

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* 27. Section 5 - Illegal drugs - How often and how much at a time?

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* 28. Section 5 - Family History

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* 29. Section 5 - Current or Recent Symptoms

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* 30. Section 5 - If you selected Bleeding, please describe:

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* 31. Section 5 - If you selected Pain, please describe:

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* 32. Section 5 - If you selected Rash/itching, please describe: