and bring a copy with you to your appointment UNIVERSITY DIAGNOSTIC TREATMENT CLINICS NEW PATIENT & FAMILY HISTORY Date:_________Patient Name:_____________________________________________________Date of Birth:_______________ Last First Gender: □Male □Female Marital Status: (Please check one) □Married □Single □Divorced □Widow □Other:_______________ Telephone(1st call): _________________________________Telephone(2nd call): ______________________________________ Address:________________________________________________________________________________________________ Street City State Zip Code Referring Physician: ______________________________________________________________________________________ Name Telephone Number Primary Care Physician: ___________________________________________________________________________________ Name Telephone Number What is your primary language?: ____________________________________________________________________________ Person(s) with your Medical Records Access: __________________________________________________________________ Name Relationship Telephone Have you executed a durable Power of Attorney, Directive to Physician and/or Living Will? □ Yes □ No Would you like additional information regarding these documents? □ Yes □ No If you have signed one of these legal documents then please speak to the nurse regarding your decisions and bring a copy with you to your appointment Do you have daily transportation available: □ Yes □ No I am currently: Working: □Yes □No Work Schedule is: □Full-time □Part-time □Sick Leave □Retired □Disability What type of work do you currently do or have done? ___________________________________________________________ Do you use any of the following? (Please check all that apply) Alcohol: □Yes □No What type?_____________How much?___________How often?___________If quit, when?_____________ Tobaco: □Yes □No What type?_____________How much?___________How often?___________If quit, when?_____________ Caffeine: □Yes □No What type?_____________How much?___________How often?___________If quit, when?_____________ Recreational Drugs: □Yes □No What type?_____________How much?___________How often?___________If quit, when?_____________ How much time do you spend exercising each week?_______________________________What type of exercise?____________________________ Do you need to use any of the following?(Please check all that apply) □ Cane □Walker □Wheelchair □Oxygen Other:___________________________________________________________________________________________________________________ Do you do monthly self-exams? (Please check all that apply) Skin Cancer: □Skin □Mole □Other:________________________________________ Female: Breast □Yes □No Have you ever been trained properly for breast-self exam? □Yes □No Male: Testicles □Yes □No Have you ever been trained properly for testicular self-exam? □Yes □No Are you diabetic? □Yes □No If yes, what type:______________________________________________________________________________ If yes, how is it controlled: □Diet □ Oral Medication □ Insulin □ Other:_______________________________________________________ Are you Claustrophobic (fearful of being in enclosed or narrow spaces): □Yes □No If yes, how is it controlled:_____________________________ Reproductive History: Female: Number of pregnancies:___________Number of Children:_____________Age at first Pregnancy:________________________ Did you breast feed: □ Yes □No If yes, how many months(approximate):_______________________________________ Age at first period:_____________Age at menopause(if applicable):_______________Age at last period:__________________ Hysterectomy: □ Yes □ No Ovaries in tact: □Yes □No If no, please explain: ________________________________ Hormone use: □ Yes □ No Sex drive: □Yes □No Method of birth control:_______________________________ Male: Impotence (Erectile Dysfunction) □ Yes □No Sex Drive: □ Yes □ No Page 1 of 2

UNIVERSITY DIAGNOSTIC TREATMENT CLINICS NEW PATIENT & FAMILY HISTORY Date:_________Patient Name:_____________________________________________________Date of Birth:_______________ Last First What is your understanding as to why you are being seen today:____________________________________________________ _______________________________________________________________________________________________________ Additional Medical Condition History (If additional space is needed please ask for another copy of this page) Diagnosis / Condition Physician Name Physician Office # Date Occurred Surgery / Injury / Hospitalization Physician Name / Hospital Physician Office # Date Occurred Please list the names of the hospital(s) or Clinic(s) where you had radiology tests in the last six months:____________________________ _______________________________________________________________________________________________________________ Preventive Health Maintenance (Please provide dates for each or answer none) Female: Last mammogram:______________________ Last Bone Density scan:______________________ Last pap smear: ______________________ Last pneumonia vaccine:_____________________ Last colonoscopy: ______________________ Male: Last colonoscopy: ______________________ Last PSA screening: ________________________ Last prostate exam:______________________ Last pneumonia vaccine:____________________ Is there any family history of cancer, blood disorders, cardiovascular disease, or other medical problems? If so, record below. Family Member Living Status Medical Problem Mother □Living □Deceased Grandmother(P) Father Grandfather(P) Children Aunt(s) Brother(s) Uncle(s) Sister(s) Cousin(s) Grandmother(M) Other: Grandfather(M) Patient Signature: ________________________________________________________________Date:___________________ Page 2 of 2