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Elite Urgent Care

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Elite Urgent Care

Adult New Patient Information

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Adult New Patient Information

First Name *

Middle Name *

Last Name *

Date of Birth *

Primary Phone *

Secondary Phone *

Email Address *

Gender *

Male

Female

Other

Emergency Contact

Name *

Relationship to Patient *

Email Address *

Emergency Phone *

Name/Phone of other previous providers (primary care) *

Do you see any of other providers (eye care doctor, doctor dentist, and specialist), if so please list name and phone number If known:

Preferred Pharmacy - (please provide name, address and phone number):

PRESENT MEDICATIONS- List any medications you are taking. (Include over the counter as well):

Drug Name

Strength

Frequency

Drug Name

Strength

Frequency

Any Allergies

Yes

No

(If yes please list the allergy and type of reaction)

Adult New Patient Information

Medical History

Asthma

Yes

No

Hypertension (High Blood Pressure):

Yes

No

Diabetes

Yes

No

Heart Attack

Yes

No

Kidney Disease

Yes

No

Seizures

Yes

No

Arthritis

Yes

No

Anxiety or Depression

Yes

No

COPD

Yes

No

Blood Clots

Yes

No

Stroke

Yes

No

Thyroid Disease

Yes

No

High Cholesterol

Yes

No

Liver Disease

Yes

No

Blood Transfusion

Yes

No

If yes, what year?

Cancer

Yes

No

Cancer Type?

Which Bones?

Broken Bones

Yes

No

List Any Medical Problems

Surgical History

Type

Year

Type

Year

Type

Year

Hospitalization

Reason

Year

Reason

Year

Reason

Year

Adult New Patient Information

Family History

Dad: Alive Deceased Health problems?:

Mom: Alive Deceased Health problems?:

Please list any family members with the following medical problems:

Cancer, if so what type

Heart Disease

Stroke

Autoimmune Disease (thyroid problems, lupus, rheumatoid arthritis)

Do any other conditions run in your family?:

Social History

Have you ever smoked

Yes

No

(Former smoker)How long has it been since you quit?

(If yes)How old were you when you started smoking?

How many cigarettes do you smoke a day?

Do you smoke electronic cigarettes (Vaping)?

Yes

No

Marital Status

Single

Married

Widowed

Divorced

Children (#):

Boys

Girls

Education

High School

GED College

Other

Do you consume any alcohol?

Rarely

Socially

Never

Have you ever used any drugs, including prescription drugs that were not prescribed to you?

Yes

No

(If yes) list any drugs and date of last use:

Sexually Active

Yes

No

Method of contraception or birth control (if applicable)

Do You Exercise

Yes

No

(If yes) How often (Times/week}?

Do you restrictions to your diet?(Vegetarian, diary free, gluten free)

Preventative Health

Have you ever received any of the following vaccines? Please include a date if known.

Tetanus

Yes

No

If yes please include date if known

Pneumonia

Yes

No

If yes please include date if known

Shingles/Zoster

Yes

No

If yes please include date if known

HPV Gardasil

Yes

No

If yes please include date if known

Hepatitis B

Yes

No

If yes please include date if known

Hepatitis A

Yes

No

If yes please include date if known

Flu

Yes

No

If yes please include date if known

Last Colonoscopy

Adult New Patient Information

Preventative Health

Last Bone Density Test

Women only:age at first menstrual period

Last Pap Smear

Last Mammogram

Date of last menstrual period

History of abnormal Pap

Yes

No

Number of pregnancies Miscarriages Terminations Living childrens

Over the past two weeks, have you been bothered by any of the following problems?

1. Little interest or pleasure in doing things

Not at all

Several days

More than half the day

Nearly everyday

2. Feeling down, depressed, or hopeless

Not at all

Several days

More than half the day

Nearly everyday

If you answered not at all to both questions, you have completed the screening, otherwise please continue. If negative please skip to question 10

3. Trouble falling or staying asleep, or sleeping too much

Not at all

Several days

More than half the day

Nearly everyday

4. Feeling tired or having little energy

Not at all

Several days

More than half the day

Nearly everyday

5. Poor appetite or overeating

Not at all

Several days

More than half the day

Nearly everyday

6. Feeling bad about yourself or that you are a failure or have let yourself or your family down

Not at all

Several days

More than half the day

Nearly everyday

7. Trouble concentrating on things, such as reading : the newspaper or watching television

Not at all

Several days

More than half the day

Nearly everyday

8. Moving or speaking so slowly that other people could have noticed, Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual

Not at all

Several days

More than half the day

Nearly everyday

9. Thought that you would be better off dead, or of hurting yourself in some way?

Not at all

Several days

More than half the day

Nearly everyday

Adult New Patient Information

Preventative Health

Over the last 2 weeks, how often have you been bothered by the following?

10. Feeling nervous, anxious or on edge

Not at all

Several days

More than half the day

Nearly everyday

11. Not being able to stop or control worrying

Not at all

Several days

More than half the day

Nearly everyday

12. Worrying too much about different things

Not at all

Several days

More than half the day

Nearly everyday

13. Trouble relaxing

Not at all

Several days

More than half the day

Nearly everyday

14. Being so restless that-it is hard-to-sit-still

Not at all

Several days

More than half the day

Nearly everyday

15. Becoming easily annoyed or irritable

Not at all

Several days

More than half the day

Nearly everyday

16. Feeling afraid as if something awful might happen

Not at all

Several days

More than half the day

Nearly everyday

If age 65 or older:

1. Do you need help with transportation, shopping, meal preparation, self-care such as bathing or getting dressed, laundry, housework, or managing money or medication?

Yes

No

2. Do you have loose rugs on your floors, poor lighting, stairs or bathroom without handrails?

Yes

No

3. Do you notice significant hearing loss

Yes

No

4. Do you have a significant change in vision?

Yes

No

5. Have you noted any significant change in your ability to remember things or take care of your finances/business or is your family concerned about your memory?

Yes

No

6. Have you had 2 or more falls in the past year?

Yes

No

7. Have you had any falls with significant injury in the past year?

Yes

No

8. Do you have an advanced directive?

Yes

No

Patient Name

Date

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