DOYLESTOWN THYROID & ENDOCRINE ASSOCIATES NEW PATIENT HEALTH QUESTIONNAIRE Date of Visit * Name * Age * What is the chief reason you are being seen today? * Please list all medical problems or surgeries for which you have been diagnosed or treated : Please list any surgeries or hospitalizations (include dates, if known) : Are there any symptoms you are concerned about today? If so, please list: SOCIAL ISSUES Do you smoke? YESNO Packs per day Age when started Do you drink alcohol? YESNO How many alcoholic drinks/ day? 01/21234more than 4 Do you use illicit drugs? YESNO If so, what kind? Marital Status SingleMarriedDivorced/SeparatedWidowed What is your occupation? FAMILY MEDICAL HISTORY Is there a family history (blood relatives only) of the following conditions? If so, circle and write how family member is related to you. (i.e. mother/ father, sister/ brother, grandparent, etc.) Diabetes High Blood Pressure High Cholesterol Heart Disease Obesity Cancer Osteoporosis Calcium Problems Thyroid Are there other diseases/ conditions which run in your family? MEDICATIONS (please list med name, dose and how often you take it) DRUG ALLERGIES (please list, if any) FOR DIABETES PATIENTS ONLY: (skip the rest of this form if you do not have diabetes) How long have you had diabetes? Are you diagnosed as Type 1 or Type 2? How many times a day do you check your sugar? What is the range of numbers you see? Are you using a Continuous Glucose Sensor? If so, what type? (Continuous Glucose Sensor) Please list any diabetes meds which have been unsuccessful for you : Have you ever been hospitalized for diabetes? YESNO Have you needed help from another person to recover from a low blood sugar? YESNO Do you have a glucagon emergency kit? YESNO Do you have numbness, tingling or pain in your feet or legs? YESNO Have you had a flu shot this year? YESNO Have you ever had a vaccination for pneumonia? YESNO Have you ever been vaccinated for COVID-19? YESNO Have you ever been told of bleeding or diabetic changes in your eyes? YESNO When was the last time you saw an eye doctor for a diabetes eye exam? Who is your eye doctor and what town are they in? Have you ever had a heart attack or been told you have coronary artery disease? YESNO Do you have a cardiologist? YESNO If so, who is it? Thank you! Doylestown Thyroid & Endocrine Associates
