1. 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
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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:___________________
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