Medical History - Dr. Nasser's New Patient Questionnaire

As a new patient, you have a lot of background to share with a new physician. Use this template when you are visiting a physician or specialist for the first time. Fill this out to bring with you to the appointment to simplify the registration process. Keep a copy for your records so that it is available when you need to visit other doctors.

IMPORTANT TIP: The information you entered is not saved AND you cannot send it on line to protect your privacy. Please print this page after entering the data so you don't lose your information.

  1. Please enter the reason for your referral to my office: 

  2. Is there anyone in your family with heart disease, high blood pressure, diabetes, kidney, cancer or other medical problems?     Yes     No

    Please list any conditions and select how the person is related to you.
    Condition:      Relationship: 
    Condition:      Relationship: 
    Condition:      Relationship: 
    Condition:      Relationship: 
    Condition:      Relationship: 

  3. Enter the date of your last physical exam and list the physician who saw you.
    Month:      Date:      Year: 
    Physician: 

  4. List any medical conditions you have and for how long you've had the condition (first month/year diagnosed)
    Condition:      Month:      Year: 
    Condition:      Month:      Year: 
    Condition:      Month:      Year: 
    Condition:      Month:      Year: 
    Other:     Month:      Year: 

  5. Have you ever gone to an emergency room for treatment in the last year?     Yes     No
    How many times in the past year? 
    List the reason and when you made each ER visit.
    Reason:      Month:      Year: 
    Reason:      Month:      Year: 
    Reason:      Month:      Year: 

  6. Have you ever stayed in the hospital overnight during the past year?     Yes     No
    How many times in the past year? 
    List the reason and when you stayed overnight.
    Reason:      Month:      Year: 
    Reason:      Month:      Year: 
    Reason:      Month:      Year: 

  7. Have you had surgery?     Yes     No
    List the type of surgery or reason for surgery including dates.
    Reason:      Month:      Year: 
    Reason:      Month:      Year: 
    Reason:      Month:      Year: 

  8. List any allergies you have to food or medications. Tip: Only 5 lines available, so summarize.

  9. Have you ever had an anaphylactic reaction (turning red, overall swelling, difficulty breathing)?     Yes     No

  10. Do you smoke?     Yes     No
    Select which products you use, how much, and number of years used.
    Tobacco product: 
    How much: 
    Years: 

  11. Do you drink alcohol?     Yes     No
    How many of each do you drink a day?
    Beer:      Wine:      Liquor: 

  12. Are you taking any prescription drugs currently?     Yes     No
    List drugs, dosage, and how often you take them.
    Drug Name:      Dosage:      How often: 
    Drug Name:      Dosage:      How often: 
    Drug Name:      Dosage:      How often: 

  13. Do you have pain to your legs when you walk?     Yes     No
    Which leg?     Right     Left
    Select where it hurts, how long do you walk before it hurts, and number of months/years you have had it.
    Where is the pain : 
    How long do you walk before you have to stop(Street Blocks or distance): 
    How long has this been bothering you (Months/Years): 

  14. (Your Additional Question Goes Here.) Tip: Only 5 lines available, so summarize.

IMPORTANT TIP: The information you entered is not saved AND you cannot send it on line to protect your privacy. Please print this page after entering the data so you don't lose your information.

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