New Patient Questionnaire

Date:
Name:
Address:


City	State	Zip

Sex: Male Female
Marital Status:
Occupation:
Age:		Date of Birth:
Work Phone:
Home Phone:

Symptoms:
Please check if any of the following apply to you NOW or in the PAST.

Yes \| No	Head, Eyes, Ears, Nose, Throat
	Noise Exposure
	Head Injury or Concussion
	Draining or Painful Ears
	Hearing Loss
	Ringing in Ears
	Dizziness or Loss of Balance
	Chronic Facial Pain or Headaches
	Chronic Nasal Congestion or Drainage
	Frequent Nose Bleeds
	Difficulty Swallowing
	Hoarseness
	Throat Pain
	Jaw Pain
	Chronic Cough
	Tooth Pain / Loose Teeth / Bite Problems
	Snoring / Sleep Apnea
	Double Vision / Eye Pain / Change in Vision
	General
	Unexplained Fever / Night Sweats
	Unexplained Weight Loss or Gain
	Joint Pains and Swelling
	Lungs
	Coughing up Blood *Shortness of Breath
	Abnormal Chest X-ray
	Heart - Circulation
	Leg Vein Trouble / Leg Pain When Walking
	Ankle Swelling
	Chest Pain
	Heart Palpitations

Past Surgeries: List type of operation and date:

	Stomach - Intestinal
	Heartburn or Regurgitation
	Indigestion
	Frequent or Severe Stomach Pain
	Frequent or Severe Vomiting
	Vomiting Blood
	Urinary
	Frequent Urination / Trouble Holding Urine
	Trouble Starting Urine
	Urinate More than Two Times a Night
	Nervous System
	Fainting Spells (Blackouts)
	Convulsions (Seizures, Fits, Epilepsy)
	Tremor (Shaking, Trembling)
	Paralysis (or Weakness in Any Body Part)
	Numbness (body parts "Go to Sleep")
	Females
	Pregnant
	Date of Last Period:

Past Medical History: List type of illness, place, and date:

Medications: What prescribed medicines are you taking? (List dose and frequency.) Include non-prescription medicines, herbal supplements and/or vitamins. Attach separate sheet if space below is not sufficient.

Drug Allergies / Reactions:

Are you allergic to latex? Yes No

Health History: Have you had any of the following?
Yes \| No
	Cancer (Type)
	Heart murmur
	High Blood Pressure
	Liver Disease, yellow jaundice, hepatitis
	Mental troubles or nervous breakdown
	Pneumonia
	Artificial joints or heart valves
	Do you take antibiotics when you go to the dentist?
	Serious injury / accident
	Diabetes
	Tuberculosis (TB)
	Uncontrolled bleeding
	Kidney disease
	HIV/AIDS
	Difficulty with anesthetic
	Heart Attack
	Thyroid disease
	Abnormal EKG
	Stroke
	Facial fracture or jaw fracture
	Have you used aspirin within the last two weeks?
	How much?

Family Health:

Physician Signature: ___________________ Date:_______

Physician Review Date: ____________________ Initials:________

New Patient Questionnaire Send this form to the office located in: GastoniaShelbyBelmont

New Patient Questionnaire Send this form to the office located in: