DOYLESTOWN THYROID & ENDOCRINE ASSOCIATES

NEW PATIENT HEALTH QUESTIONAIRE

Health History Electronic Form

    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
    Fevers
    General Weakness
    Weight Gain
    Weight Loss
     
    HEENT
    Eyesight Problems
    Trouble Swallowing
    Hoarseness
    Headaches
     
    Heart/Lung
    Chest Discomfort
    Irregular Heart
    Short of Breath
    Cough
    Gastrointestinal
    Abdominal Pain
    Nausea
    Vomiting
    Diarrhea
    Constipation
     
    Genitourinary
    Difficulty Urinating
    Pain Urinating
    Menstrual Irregularity
    Erectile Dysfunction
     
    Neurological
    Numbness
    Tingling
    Weakness
    Endocrine
    Cold or Heat Intolerance
     
    Muscle/Bone
    Joint Pain
    Broken Bones
     
    Psychological
    Depression
    Anxiety
     
    Hematological
    Bruising
    Bleeding
     
    Skin
    Dry Skin
    Rash
    Acne

    SOCIAL ISSUES

    Do you smoke?
    Packs per day
    Age when started
    Do you drink alcohol?
    How many drinks/week?
    Do you use illicit drugs?

    CURRENT MEDICATIONS

    Name of Medication Name of Dosage
    Name of Medication Name of Dosage
    Are you allergic to any medication?

    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.

    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?
    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?
    Do you have a glucagon emergency kit?
    Do you have numbness, tingling or pain in your feet or legs?
    Have you had a flu shot this year?
    Have you ever had a vaccination for pneumonia?
    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?
    Have you ever had a heart attack or been told you have coronary artery disease?
    Do you take a daily aspirin?

    Thank you!
    Doylestown Thyroid & Endocrine Associates