ANCZ01 New Patient Assessment Form

NEW PATIENT ASSESSMENT FORM

Patient Name *

First Name

Middle Name

Last Name

Date of Birth *

Date

Symptoms you are CURRENTLY experiencing

EYES, EARS NOSE THROAT

HEART/LUNGS

	Yes	No	Details
Shortness of breath
Bloody sputum/coughing up blood
Chest pain
Trouble breathing at night
If yes above, # pillows you sleep on? State in Details column
Cough

GASTROINTESTINAL

	Yes	No	Details
Nausea/ Vomiting
Diarrhea
Constipation
Hemorrhoids
Reflux
Blood with bowel movements or dark tarry stools
Colonoscopy
Feeding Tube
Stomach Ulcers
Weight loss (State amount and date in Details column)

GENITO-URINARY

SKIN

NEUROLOGICAL

MUSCULOSKELETAL

	Yes	No	Details
Joint pain (State location in Details column)
Osteoporosis/osteopenia

ENDOCRINE

	Yes	No
Diabetes

PAST MEDICAL HISTORY

Past Medical History

	Yes	No	Details
Previous cancer - list Type/Dates in Details Column
Radiation Therapy-list Type/Dates/Facility in Details Column
Chemotherapy -list Type/Dates/Facility in Details Column
Hormone Therapy-list Type/Dates/Facility in Details Column
Lupus/Scleroderma/ Rheumatoid arthritis
High blood pressure
Stroke
Pacemaker
Heart failure
Heart attack
Blood clots
Asthma
COPD
Kidney failure
Sleep apnea
TB (treated)
Positive TB test
Hepatitis
Thyroid issues
Arthritis

Sex

Male

Female

GYN HISTORY

Age at first menstruation (period)?

Cycle (Days)

Is your cycle regular at this time?

Yes

No

Use of birth control pills

Yes

No

Hormone replacement therapy

Yes

No

Age at menopause

Age at first term delivery

Number of pregnancies

Number of live births

Previous breast biopsies

Yes

No

PAST SURGICAL HISTORY

	Surgery	Year
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

MEDICATIONS

	Medication	Dose
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

ALLERGIES

Medication/food allergies/seasonal:

SOCIAL HISTORY

Functional disabilities, assistive, prosthetic devices:

Currently lives in:

Smoking history

Yes

No

Packs per day

Number of years

Quit?

Chewing tobacco

Yes

No

Packs per day

Number of years

Quit?

Alcohol use

Yes

No

Drinks per day

Quit?

Exercise – Type and frequency:

Primary language:

Birthplace:

Marital status:

Name of spouse

First Name

Last Name

Recent travel outside of Alaska with location and dates:

Present/previous work:

Environmental exposures:

Interests/hobbies:

Support person/people/spiritual support:

FAMILY HISTORY

	Alive/age	Deceased/age	Cause of death or health concerns
Mother
Father
Sisters
Brothers
Grandparents

	Yes	No
Weight loss (past 6 months)
Hearing loss
Pain/Difficulty swallowing
Dentures
New lumps in neck or throat

	Yes	No
Painful urination
Urinary incontinence
Urgency/Frequency
Blood in urine

	Yes	No
Headaches
Focal weakness/numbness
Seizures
Balance problems/dizziness
Anxiety/Depression
Loss of bowel or bladder control
Fall Risk

	Yes	No	Details
Rashes
Sores
Vein access R/L, Port or Central Venous Catheter (State preference in Details column)