DOYLESTOWN THYROID & ENDOCRINE ASSOCIATES NEW PATIENT HEALTH QUESTIONAIRE Health History Electronic Form Email * Phone Number * Name * Age * Date of Visit * What is the chief reason you are being seen today? * Please list all medical problems or surgeries for which you have been diagnosed or treated : SYMPTOM REVIEW: (We recommend that you also discuss any symptoms with your regular doctor) Please check mark Yes or No for any of these symptoms that have bothered you recently: General Fatigue YESNO Fevers YESNO General Weakness YESNO Weight Gain YESNO Weight Loss YESNO HEENT Eyesight Problems YESNO Trouble Swallowing YESNO Hoarseness YESNO Headaches YESNO Heart/Lung Chest Discomfort YESNO Irregular Heart YESNO Short of Breath YESNO Cough YESNO Gastrointestinal Abdominal Pain YESNO Nausea YESNO Vomiting YESNO Diarrhea YESNO Constipation YESNO Genitourinary Difficulty Urinating YESNO Pain Urinating YESNO Menstrual Irregularity YESNO Erectile Dysfunction YESNO Neurological Numbness YESNO Tingling YESNO Weakness YESNO Endocrine Cold or Heat Intolerance YESNO Muscle/Bone Joint Pain YESNO Broken Bones YESNO Psychological Depression YESNO Anxiety YESNO Hematological Bruising YESNO Bleeding YESNO Skin Dry Skin YESNO Rash YESNO Acne YESNO SOCIAL ISSUES Do you smoke? YESNO Packs per day Age when started Do you drink alcohol? YESNO How many drinks/week? 01/21234more than 4 Do you use illicit drugs?YESNO What is your occupation? CURRENT MEDICATIONS Name of Medication Dosage Name of Medication Dosage Are you allergic to any medication?YESNO If yes, list FAMILY MEDICAL HISTORY Please list any relevant family history of medical conditions (blood relatives only) below. We are particularly interested in history of diabetes, heart disease, cancer, thyroid, adrenal, pituitary or other glandular or hormonal conditions. Please List Here: FOR DIABETES PATIENTS ONLY: (skip the rest of this form if you do not have diabetes) How long have you had diabetes? Have you ever been hospitalized for diabetes? YESNO How many times a day do you check your sugar? What is the range of numbers you see? Have you needed help from another person to recover from a low blood sugar? YESNO Do you have a glucagon emergency kit? YESNO Do you have numbness, tingling or pain in your feet or legs? YESNO Have you had a flu shot this year? YESNO Have you ever had a vaccination for pneumonia? YESNO When was the last time you saw an eye doctor for a diabetes eye exam? Who is your eye doctor? Have you ever been told of bleeding or diabetic changes in your eyes? YESNO Have you ever had a heart attack or been told you have coronary artery disease? YESNO Do you take a daily aspirin? YESNO Thank you! Doylestown Thyroid & Endocrine Associates
