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?

CURRENT MEDICATIONS

Name of Medication Name of Dosage
Name of Medication Name of Dosage

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 any 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