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New Patient Record
What brings you to the hospital/office today?
Do you think about harming yourself?
Select Yes or No
Yes
No
Describe your symptoms and severity:
If yes, have you had these symptoms before?
Select Yes or No
Yes
No
What medical conditions do you have?
List medications/supplements and dosage:
Do you have allergies?
Select Yes or No
Yes
No
If yes, list your allergies:
Does the patient have insurance?
Select Yes or No
Yes
No
If yes, which insurance?
Have you had past surgeries?
Select Yes or No
Yes
No
If yes, describe your surgeries:
Family disease history?
Select Yes, No, or Unsure
Yes
No
Unsure
If yes, list family diseases:
Do you smoke or use tobacco?
Select Yes or No
Yes
No
If yes, describe usage:
Do you drink alcohol?
Select Yes or No
Yes
No
If yes, describe usage:
Any important spiritual/cultural beliefs?
Select Yes or No
Yes
No
If yes, describe:
Do you consent to the proposed treatment?
Select Yes or No
Yes
No
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