New Patient Questionnaire Form
Please complete the form, print it out, and bring to your appointment.


Name:
Age: Height: Weight:
Employer: Occupation:
Family Doctor: Telephone:
Referring Doctor: Telephone:
1. Do you take aspirin (if yes) have you taken it in the past week? Yes No
   (if yes) how much and how often?
   Motrin or other anti-inflammatory drugs? Yes No
   (if yes) how much and how often?
2. Do you have any bleeding tendencies? Yes No
3. Have you taken any cortisone or steroids in the past 6 months? Yes No
4. Do you have a cold? Yes No
5. Do you have a chronic cough? Yes No
6. Have you ever had a problem with anesthesia? Yes No
7. Has anyone related to you ever had a problem with anesthesia? Yes No
8. Have you had asthma? Yes No
9. Have you had difficulties with breathing? Yes No
10. Do you have sleep apnea? (or episodes of breathing problems during sleep? Yes No
11. Do you have a heart murmur? Yes No
12. Have you ever had a heart attack? Yes No
13. Have you ever had angina or pain in your chest? Yes No
14. Could you be pregnant? Yes No
15. Have you been an alcoholic? Yes No
16. Have you ever been treated for drug abuse, addiction or overdose? Yes No
17. Have you been convicted of a crime? Yes No
18. Do you have more than 2 alcoholic drinks (or beer/wine) per day? Yes No
19. Have you ever been jaundiced (yellow - skin or eyes) Yes No
20. Have you ever had hepatitis? Yes No
21. Do you have heartburn, hiatus hernia or ulcers? Yes No
22. Do you have diabetes? Yes No
23. Do you have kidney disease? Yes No
24. Are under treatment for high blood pressure? Yes No
25. Have you had epilepsy, seizures, or fainting spells? Yes No
26. Have you ever had a stroke? Yes No
27. Do you have an arm or leg that becomes numb or weak frequently? Yes No
28. Do you have any limited motion? Yes No
29. Do you have any chipped or loose teeth, dentures, caps, bridgework, braces Yes No
30. Can you climb two flights of stairs? Yes No
31. Do you Keloid or scar badly? Yes No
32. Have you had any thyroid problems? Yes No
33. Are you under the care of a Psychiatrist? Yes No
34. Have you ever been under the care of a psychiatrist? Yes No
35. Do you have headaches Yes No   Migraines? Yes No
36. Do you smoke? Yes No   Packs per day?
    Start Age   Smokers Cough? Yes No
   If you quit --- Start age   Quit age?
37. Have you had tuberculosis? Yes No   38. Syphilis or VD? Yes No
39. Lyme Disease? Yes No   40. HIV? Yes No
41. Rheumatoid Arthritis Yes No   42. Osteoarthritis? Yes No
Are you currently taking any prescription medications? Yes No
   If yes, please list all medications you are taking (including over the counter including vitamins, herbal products and dietary supplements.)

   
43. Please list all allergies you have
   Penicillin Yes No   Sulfa Drugs Yes No
   Latex Products Yes No   Aspirin Yes No
   X-ray Dye Yes No        
Other Drugs or products

   
44. Please check off all surgeries you have had and dates if possible:
Appendectomy   Hernia
Tonsillectomy   Hysterectomy
Prostate   Heart Bypass
Cataract   Gall Bladder
C-Section   D&C
Back   Neck
Other (list)

   
45. Family history Spinal Disease/Injuries? Yes No
46. Family history RSD? Yes No
47. Has anyone in your family been convicted of a crime? Yes No
48. Are you unusually nervous about surgery or injections? Yes No
49. Family history Spinal or Other Medical Problems? Yes No
Comments: if any of the above are yes or if you feel that the doctor should know of importance that is not already mentioned

   

 

Copyright © 2006, Kenneth Zahl, M.D.
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