NEW PATIENT EVALUATION FORM - My Passion 4 Health
Please fill out this form for your upcoming appointment with Dr Mary Ackerley.
Email address *
Today's date *
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YYYY
Full name *
Your answer
Date of birth *
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DD
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YYYY
Home address (street, city, state, zip) *
Your answer
Home phone
Your answer
Work phone
Your answer
Cell phone
Your answer
Sex *
Employment status *
Occupation (if working)
Your answer
Employer (if working)
Your answer
Referred by
Your answer
Marital status *
Number of children
Your answer
Person to be contacted in case of emergency (name, address, phone)
Your answer
Hospitalizations: Start with most recent and list type of illness, month and year hospitalized, name of hospital, city, and state
Your answer
Allergies
Your answer
Medications: type, dosage, frequency
Your answer
Supplements
Your answer
Comments/special problems: The main reason for seeing Dr. Ackerley
Your answer
Check if you have been bothered recently by any of these problems *
Required
Men only
Women only
Women only - # of pregnancies
Your answer
Women only - # of births
Your answer
Women only - # of miscarriages
Your answer
Women only - # of premature births
Your answer
Women only - # of caesarean sections
Your answer
Women only - What symptoms do you experience premenstrually?
Your answer
What are you most sensitive to (e.g. noise, odors, light, pain)?
Your answer
Describe an ideal day in terms of weather and temperature
Your answer
What are your fears?
Your answer
Describe your hobbies
Your answer
How is your sexual interest/drive?
Low
High
Family History: Check columns for any illnesses that you or your relatives have had (may need to use scroll bar at bottom)
Self
Father
Mother
Brothers
Sisters
Child #1
Child #2
Grandparent
Allergies
Anemia
Arthritis/Gout
Asthma
Bleeding problems
Cancer
Epilepsy
Diabetes
Alcohol/Drugs
Eczema
Psoriasis
Emphysema
Heart trouble
Hepatitis
High Blood Press.
Frequent Infections
Kidney Problems
Mental Illness
Migraines
Abnormal periods
Pneumonia
Polio
Prostate problems
Rheumatic fever
Stomach problems
Stroke
Thyroid problems
Tuberculosis
Ulcers
Venereal disease
Weight problems
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