ANCZ01 New Patient Assessment Form

NEW PATIENT ASSESSMENT FORM

Patient Name*

First NameMiddle NameLast Name

Date of Birth*

Date

Symptoms you are CURRENTLY experiencing

EYES, EARS NOSE THROAT

Rows	Yes	No
Weight loss (past 6 months)
Hearing loss
Pain/Difficulty swallowing
Dentures
New lumps in neck or throat

HEART/LUNGS

Rows	Yes	No	Details
Shortness of breath
Bloody sputum/coughing up blood
Chest pain
Trouble breathing at night
If yes above, # pillows you sleep on? State in Details column
Cough

GASTROINTESTINAL

Rows	Yes	No	Details
Nausea/ Vomiting
Diarrhea
Constipation
Hemorrhoids
Reflux
Blood with bowel movements or dark tarry stools
Colonoscopy
Feeding Tube
Stomach Ulcers
Weight loss (State amount and date in Details column)

GENITO-URINARY

Rows	Yes	No
Painful urination
Urinary incontinence
Urgency/Frequency
Blood in urine

SKIN

Rows	Yes	No	Details
Rashes
Sores
Vein access R/L, Port or Central Venous Catheter (State preference in Details column)

NEUROLOGICAL

Rows	Yes	No
Headaches
Focal weakness/numbness
Seizures
Balance problems/dizziness
Anxiety/Depression
Loss of bowel or bladder control
Fall Risk

MUSCULOSKELETAL

Rows	Yes	No	Details
Joint pain (State location in Details column)
Osteoporosis/osteopenia

ENDOCRINE

Rows	Yes	No
Diabetes

PAST MEDICAL HISTORY

Past Medical History

Rows	Yes	No	Details
Previous cancer - list Type/Dates in Details Column
Radiation Therapy-list Type/Dates/Facility in Details Column
Chemotherapy-list Type/Dates/Facility in Details Column
Hormone Therapy-list Type/Dates/Facility in Details Column
Lupus/Scleroderma/ Rheumatoid arthritis
High blood pressure
Stroke
Pacemaker
Heart failure
Heart attack
Blood clots
Asthma
COPD
Kidney failure
Sleep apnea
TB (treated)
Positive TB test
Hepatitis
Thyroid issues
Arthritis

MaleFemale

GYN HISTORY

Age at first menstruation (period)?

Cycle (Days)

YesNo

Age at menopause

Age at first term delivery

Number of pregnancies

Number of live births

YesNo

PAST SURGICAL HISTORY

Rows	Surgery	Year
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

MEDICATIONS

Rows	Medication	Dose
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

ALLERGIES

Medication/food allergies/seasonal:

SOCIAL HISTORY

Functional disabilities, assistive, prosthetic devices:

Currently lives in:

YesNo

Packs per day

Number of years

Quit?

YesNo

Packs per day

Number of years

Quit?

YesNo

Drinks per day

Quit?

Exercise – Type and frequency:

Primary language:

Birthplace:

Marital status:

Name of spouse

First NameLast Name

Recent travel outside of Alaska with location and dates:

Present/previous work:

Environmental exposures:

Interests/hobbies:

Support person/people/spiritual support:

FAMILY HISTORY

Rows	Alive/age	Deceased/age	Cause of death or health concerns
Mother
Father
Sisters
Brothers
Grandparents