New patients to  our practice are requested to complete the following form and bring it with them to their first visit.

Centennial Medical Group                Name ________________________________________
Patient Medical History                    Date of Birth ____________    Date ____________

What are your current concerns about your health?
__________________________________________________________
Please circle if you have had any of these medical problems in the past:

Stroke/TIA; Substance abuse; Psychiatric disease; Glaucoma; Migraines; Seizures; Chronic sinusitis; Hypertension; Heart disease; Valvular disease, Murmur, Elevated cholesterol; Asthma; COPD/Emphysema; Tuberculosis; Pneumonia; Peptic ulcer disease; GERD/Gastro-esophageal reflux; Irritable bowel; Hepatitis, Gallbladder disease; Anemia; Arthritis; Prostate problems; Kidney stones; DVT/blood clots; Cancer, Skin disease; Diabetes mellitus; Thyroid disease; Osteoporosis; Abnormal pap Smear; Sexually transmitted diseases; Herpes; Syphilis; Gonorrhea; HIV; Other ____________________________________________________________________
Last Menstrual Period ______________________
PREVIOUS HOSPITALIZATIONS: (Please list date and reason) ___________________________________________________________________
___________________________________________________________________ ___________________________________________________________________
PAST SURGICAL HISTORY: (Please list if you have had any surgery)
[None]; [Appendectomy]; [Hysterectomy]; [Tonsillectomy]; [Cholecystectomy]; [Hernia Repair];
[Sinus surgery]; [Vasectomy]; [Tubal Ligation]; [Cataract]; [Other]:_____________________________________________________________

IMMUNIZATIONS:
Please list the dates of your most recent immunizations:
Tetanus/diphtheria ________________MMR#1___________; MMR #2  _________;
Polio________________; Hepatitis B series completed _____________________;
Influenza vaccine_____________;              Pneumovax _____________________;
Lyme vaccine _______________;               Meningococcal vaccine_____________;
Hepatitis A __________________;              Chickenpox ______________________;

Please list the dates of any of the following procedures that you have had performed:

Rectal examination_____________      Chest x-ray _______________________
Bone density _________________       Flexible sigmoidoscopy _____________
EKG ________________________     Colonoscopy ______________________
Stress test ___________________       PSA ____________________________
Mammogram _________________       Pap smear ________________________  
Cholesterol level ______________

HABITS/SOCIAL:

How are you currently employed? _____________________
Have you been exposed to any toxin (i.e. asbestos, lead, pesticides, or chemicals)? __________
Do you smoke cigarettes? _______________ How much? _______________
Do you chew tobacco? __________________  
How many alcoholic drinks do you have in one week? ___________________
How many caffeinated beverages (including colas) do you consume daily? __________
Do you watch your diet to restrict salt, fat or meat? ___________________
Do you do regular aerobic exercise?  ________        How many times a week? _______
Do you have trouble falling asleep?    _________
Do you have trouble staying asleep? _________
Do you snore? __________              Do you feel rested in the morning? ________________
Do you wake up earlier in the morning than you should? __________
Do you experience daytime drowsiness? ___________
Do you use seatbelts while driving? ___________
What is your marital status? _____________ How many children do you have? _________
Are you sexually active? ________________
What do you use for birth control? ________________

TRANSFUSION HISTORY:
Have you ever received a blood transfusion? ______________

FAMILY HISTORY:  Do your family members have a history of any of the following diseases:
Hypertension, Heart Disease, Diabetes Mellitus, High Cholesterol, Asthma, Arthritis, Glaucoma, Cancer, Thyroid Problems, Osteoporosis, Gout, Others:__________________________________________________________

Review of Systems: Please circle if you have had any of these symptoms recently:

Fatigue; recent weight change; fever; chills; sweats; difficulty sleeping; excessive snoring;
Itching eyes; discharge from eyes; redness in your eyes; change in vision;
Changes in hearing; ringing in your ears;
Nasal congestion, nosebleeds -; frequent sore throat -; dental problems -; hoarseness
Cough; shortness of breath -; wheezing -; coughing up blood -;
Chest pain or pressure with exertion -; palpitations -; edema -; difficulty lying flat,
Nausea -, vomiting -; diarrhea -, constipation -; trouble swallowing-;
Changes in bowel habits -; jaundice -, abdominal pain -; blood in stool -;
Difficulty urinating -, pain with urination -, blood in urine -;
Increased frequency of urination; waking up to urinate at night -;
Irregular periods -; heavy periods -; vaginal discharge -;
Muscle pain -; muscle weakness -; joint pain -; limited movement of joints -;
Rash -; itching of skin; change in moles; cold extremities; loss of hair on your legs;
Headaches -; numbness -; “pins and needles” feelings -;
Problems with balance -; tremor -;
Anxiety -; suicidal thoughts -; changes in mood -;
Increased thirst or urination, heat or cold intolerance -; easy bruising -; abnormal bleeding -; Lymph node swelling -; hives; seasonal runny nose