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New Patient Questionnaire
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New Patient Questionnaire
New Patient
Demographics
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Married
Single
Widowed
Divorced
Pharmacy Info
Insurance Info (Please bring insurance Card to visit)
Emergency contact
Would you like us to communicate with you by email?:
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No
***Physical signature will be required upon office visit.***
Receipt of Privacy Practices (HIPPA)
I have received a copy of Rebecca Kurth, MD's Notice of Privacy Practices:
Yes
No
***Physical signature will be required upon office visit.***
New Patient
Questionnaire
Social Background
Family Background
Please list date of birth and health status of your parents and any siblings. If deceased, please list their age(s) and the possible cause of death:
Please check any of the following illnesses that have affected your family (include only parents, grandparents, and siblings):
Diabetes
High Cholesterol
Stroke
Breast Cancer
Heart Attack
High Blood Pressure
Asthma
Thyroid Disease
Colon Cancer
Alzheimer's Disease
Depression
Prostate Cancer
General Review
Do you excersise regularly?
Yes
No
Over the past year have you lost or gained weight?
Yes
No
Are you happy with your current weight?
Yes
No
Please check any of the following symptoms that you may be experiencing:
General
Fatigue
Hot Flashes
Tiredness
Night Sweats
Head and Neck
Headaches
Change In Vision
Double Vision
Blurred Vision
Sore Throat
Sinus Problems
Tingling In Hands
Hoarseness
Lumps In Neck
Pain In Neck
Weakness In Hands
Lungs
Wheezing
Cough
Shortness Of Breath
Do you have any history of the following:
Pneumonia
Asthma
Pulmonary Embolism
Tuberculosis
Bronchitis
Emphysema
Positive TB Skin Test
Heart
Palpitations
Chest Pain
Lightheadedness
Dizziness
Chest Tightness
Racing Heart
Do you have any history of:
Rheumatic Fever
Cigarette Smoking
High Blood Pressure
Heart Murmur
High Cholesterol
Mitral Valve Prolapse
Heart Attack
Diabetes
Atrial Fibrillation
Have you ever had any of the following:
Stress Testing
Echocardiogram
Cardiac Catheterization
Abdomen
Pain
Blood In The Stool
Indigestion
Diarrhea
Constipation
Incontinence
Do you have a history of the following:
Colon Cancer
Colon Polyps
Hemorrhoids
Peptic Ulcer Disease
Gallstones
Crohn's Disease
Ulcerative Colitis
Irritable Bowel Syndrome
Have you ever had the following:
Colonoscopy
Barium Enema
Stool For Occult Blood
Sigmoidoscopy
Endoscopy
CAT Scan Of Your Abdomen
Muscular-skeletal system
Pain in:
Shoulders
Back
Knees
Hips
Feet
Elbows
Hands
Neck
Swelling in:
Shoulders
Knees
Feet
Elbows
Hands
Do you have any history of the following:
Osteoarthritis
Rheumatoid Arthritis
Gout
Seleroderma
Lupus
Temporal Arthritis
Lyme Disease
Herniated Discs
Endocrine
Increased Thirst
Increased Nightly Urination
Increased Appetite
Change In Size Of Gloves Or Hat
History Of Diabetes
Parathyroid Problems
Thyroid Problems
Do you have a history of the following:
Diabetes
Thyroid Disease
High Cholesterol
Osteopenia
Parathyroid Disease
Osteoporosis
Hematologic
B12 Deficiency
Bleeding Disorder
Sickle Cell Disease
Anemia
Leukemia
Easy Bleeding
Easy Bruising
Lymphoma
Neurologic
Trouble With Speech
Stroke
Weakness In The Arms/Legs
Myasthenia Gravis
Tingling
Memory Problems
Tremors
Parkinson's Disease
Headache
Multiple Sclerosis
Paralysis
Dermatologic
Rash
Moles
Itching
Hair Loss
Nail Discoloration
Mood
Depressed
Down
Anxious
Blue
Panicky
Irritable
Stressed Out
Worried
Nightmares
Overeating
Bulimia
Anorexia
Thoughts Of Hurting Yourself
Do you have a history of the following:
Depression
Panic Attacks
Bipolar Disorder
Anorexia
Bulimia
Schizophrenia
Domestic Violence
Anxiety
Are there any other emotional issues that you would like to discuss?
Yes
No
Men - Urinary System
Have you consulted with a urologist this year?
Yes
No
Have you had a PSA test in the past year?
Yes
No
Do you have any concerns about your sexual functioning?
Yes
No
Are you concerned about HIV risk?
Yes
No
Have you ever been tested for HIV?
Yes
No
Would you like to be tested today?
Yes
No
Do you experience:
Burning Urination
Frequent Urination
Blood In The Urine
Painful Urination
Incontinence
Difficult Urinary Stream
Lumps On Testicles
Hernias
Lumps On Groin
Women - Urinary System
Are your cycles regular?
Yes
No
Do you have any lumps in your breasts?
Yes
No
Are you concerned about HIV risk?
Yes
No
Have you ever been tested for HIV?
Yes
No
Would you like to be tested today?
Yes
No
Do you experience:
Burning Urination
Incontinence
Blood In Urine
Urinary Frequency
Travel
Do you have plans to travel outside of the US this year?
Yes
No
Immunization Dates
If you have one, please provide us with a copy of your immunization record or list the dates of your most recent vaccinations.
Exam Dates
Please supply approximate dates for the following:
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