New Patient Intake Form This form lets us get to know you and know

Date: __________________
new patient forms
Name ________________________________________
Birthdate ______________
Chart No. __________________
New Patient Intake Form
This form lets us get to know you and know how we can help. Not every question is important to everyone, but the
more you can answer, the more we can help. If there is a question that makes you uncomfortable, skip it and discuss it
during your visit. Thank you.
Do you need help with this form?  Yes  No
If you answered yes, please stop filling out the form and speak with a Front Desk staff member.
Person filling out this form (if not the patient): ___________________________________________________________
Name
Relationship to Patient
Reason for your visit today:  Routine exam
 Something is bothering me/I have something specific to discuss
for office use only
What medical problems do you have now or have you had in the past?  None
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




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
Diabetes
 Depression or anxiety
High Blood Pressure/hypertension  Thyroid problems
High cholesterol
 Migraines
Hepatitis A
 Blood clots
Hepatitis B
 Breast disease
Hepatitis C
 Allergies
Other liver problems
 Asthma
Pancreatitis
 COPD or Emphysema
Kidney failure
 Tuberculosis (TB)
Cancer
 HIV or AIDS
Addiction to: _________________________________________
Other: ________________________________________________
 None
What operations have you had in the past?

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Appendix removed
Tonsils removed
Gall bladder removed
Hernia repaired
Uterus removed (hysterectomy)
Ovaries removed (oophorectomy)
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
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Breast implants
Breast reduction surgery
Breast biopsy
Breast lumpectomy
Chest reconstruction
Other: _________________
Other than for surgery or childbirth, have you ever been in the hospital
overnight?
 Yes
 No
Has anyone in your family had any of the following?
 Diabetes
 Thyroid problems
 High cholesterol
 Osteoporosis
 High blood pressure  Parkinson’s disease
 Heart attack
 Alzheimer’s disease
 Heart surgery
 Mental illness
 Stroke
 Alcohol/drug addiction
Are you allergic to any:
medications
foods
animals/insects
 None
 Blood clots/diseases
 Breast cancer
 Colon cancer
 Ovarian cancer
 Prostate cancer
 Other: _____________
 Yes
 Yes
 Yes
 No
 No
 No
Lyon-Martin Health Services 1748 Market Street, Suite 201 ◊ San Francisco, CA 94102 ◊ (415) 565-7667
I have reviewed this page: ________
for office use only
What medicines (prescription and over-the-counter), vitamins,
supplements and/or herbs do you take regularly?
 None
Name
Dose When do you take it?
What is it for?
Do you often have trouble remembering to take
medicines?
 Yes
 No
 No
(skip to next section)
How old were you when you first got your period? _____________
What was the date that your last normal period began? ______________
What are your periods like?
I get one every
days.
It lasts for
days.
On my heaviest day, I use
___________ maxi pads/tampons.
I get cramps with my period:
 Yes
 No
If yes, how severe are they on a scale of 1 (low) to 10 (high)?
_
Have you ever gotten a period?
 unsure Yes
Have you gone through menopause?  unsure Yes
 No
(skip to next section)
At what age? ___________
Have you had any bleeding since then?
 Yes  No
Have you ever taken hormone replacement?
 Yes  No
Do you currently take hormone replacement?  Yes  No
If yes, what do you take?
 Estrogen/progesterone
 Estrogen alone
 Testosterone
 Other: ____________________
Are you having any symptoms of menopause?  Yes  No
If yes, which ones?
 Hot flashes
 Mood changes
 Vaginal dryness
 Insomnia
 other: _________________________
When was your last vaccine for:
HPV (Gardasil)
Tetanus / TdaP
Hepatitis A
Hepatitis B
Pneumonia (pneumovax)
Chicken pox (varavax)
Shingles (zostavax)
Did you receive childhood vaccinations?
date
 No
 I’m not sure
Yes
Lyon-Martin Health Services 1748 Market Street, Suite 201 ◊ San Francisco, CA 94102 ◊ (415) 565-7667
I have reviewed this page: ________
Date: __________________
new patient forms
Name ________________________________________
Birthdate ______________
Chart No. __________________
for office use only
When was the last time you had a test for tuberculosis (TB)? _________
Have you ever had a positive test for TB?
 Yes  No
If yes, did you complete ≥ 6 months of preventative treatment?
 No  Yes
If yes, which of the following symptoms do you have now?
 None
 cough > 3 weeks
 unexplained weight loss
 coughing up blood
 drenching night sweats
If no, have you had contact with someone known to have TB disease of
the lung?
 Yes
Were you born in Asia, Africa, Latin America, or Eastern Europe?
 Yes
Have you spent more than 2 weeks in Asia, Africa, Latin America,
or Eastern Europe in the past 2 years?
 Yes
Have you been in prison/jail in the past 5 years?
 Yes
Do you work with people who use drugs, are migrant workers, or
are experiencing homelessness?
 Yes
Are you a health care worker?
 Yes
When was your last:
HIV test
Sexually transmitted
infection test
Hepatitis C test
Bone density test
Cholesterol test
Date
When was your last:
Date
Cervical Pap smear
Was it ever abnormal?
Anal Pap smear
Was it ever abnormal?
Mammogram
Was it ever abnormal?
Colorectal cancer
Was it ever abnormal?
Which test(s) you’ve had:  FOBT
When was the last time you saw a dentist?
 No
 No
 No
 No
 No
 No
Result
 unsure
 never
 unsure
 never
 unsure
 unsure
 unsure
 never
 never
 never
 unsure
 Yes  unsure
 unsure
 Yes  unsure
 unsure
 Yes  unsure
 unsure
 Yes  unsure
 FIT
 Colonoscopy
 never
 never
 never
 never
 never
 never
 never
 never
 Other
Result
___________________________
How often in the past year have you had an alcoholic beverage?
 Daily or almost daily
 Less than monthly
 Weekly
 Never
 Monthly
How often in the past year have you used an illegal drug or used a prescription
medication for non-medical reasons?
 Daily or almost daily
 Less than monthly
 Weekly
 Never
 Monthly
Lyon-Martin Health Services 1748 Market Street, Suite 201 ◊ San Francisco, CA 94102 ◊ (415) 565-7667
I have reviewed this page: ________
for office use only
 No
(skip to next section)
In your lifetime your sexual partner(s) have been: (check all that apply)
 women
 transgender FTM
 genderqueer
 men
 transgender MTF
 other: ___________
Have you ever had sex with another person?
 Yes
Currently your sexual partner(s) are: (check all that apply)  none
 women
 transgender FTM
 genderqueer
 men
 transgender MTF
 other: ___________
When was the last time you had sex with another person? ________________
In the past year, how many different sexual partner(s) have you had? ________
Currently, how many sexual partner(s) do you have? _____________________
Do you only have sex with each other?
 No  Yes
Are you practicing “safer sex”?  Never  Sometimes  Always
Do you think you or your sexual partner(s) may have a
sexually transmitted infection right now?
 Yes  No
Are you having any difficulties with your sex life?  Yes  No
Do you want to discuss this today?
 Yes  No
What sexually transmitted infection(s) have you had in the past?
 None
 Gonorrhea
 Oral herpes
 Chlamydia
 Genital herpes
 Pelvic inflammatory disease
 Herpes through a blood test
 Syphilis
 Genital warts
 Trichomonas
 Other: ______________________
Have you ever been pregnant?
 Yes  No
If yes, how many times have you been pregnant? ______________
How many abortions?
____
How many premature births? ____
How many miscarriages? ____
How many full-term births?
____
How many live children do you have now? ________________________
Are you planning on getting pregnant?
If yes, when? ____________
 Yes  No
Do you or your partner(s) use any kind of birth control?
If yes, what kind? ________________________
Are you satisfied with this method?
 No  Yes
 Not needed
 No  Yes
Could you or your partner(s) be pregnant today?
 Yes  No
What would you do if you or your partner(s) got pregnant?
 N/A
_______________________________________
Have you ever been non-consensually hit, slapped, kicked,
or otherwise physically hurt by an intimate partner?
 Yes  No
If yes, when did this happen? _________________________________
Do you want to discuss this today?
 Yes  No
Have you ever been forced to have sexual activities against
your will?
 Yes  No
If yes, when did this happen? _________________________________
Do you want to discuss this today?
 Yes  No
Lyon-Martin Health Services 1748 Market Street, Suite 201 ◊ San Francisco, CA 94102 ◊ (415) 565-7667
I have reviewed this page: ________
Date: __________________
Name ________________________________________
new patient forms
Birthdate ______________
Lyon-Martin Health Services 1748 Market Street, Suite 201 ◊ San Francisco, CA 94102 ◊ (415) 565-7667
Chart No. __________________
I have reviewed this page: ________