Arond-Thomas Online | New Patient Medical History Form

New Patient Medical History Form

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.

When you submit the form, it will be emailed to you so you can keep the information safely on your computer. A copy of this information will be sent to Dr. Arond-Thomas.

Your Full Name:

Your Email Address:

Your Phone Number:

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:

List your current physicians.

	Specialty:
	Specialty:
	Specialty:

Enter the date of your last physical exam and list the physician who saw you.

Month:		Date:		Year:
Physician:

(Women only) Enter the date of your last OB/GYN exam and list the physician who saw you.

Month:		Date:		Year:
Physician:

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:
Condition:	Month:	Year:

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:

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:

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:

List any allergies you have to food or medications. Tip: Only 5 lines available, so summarize.
Have you ever had an anaphylactic reaction (turning red, overall swelling, difficulty breathing)? Yes No

Do you smoke? Yes No
Select which products you use, how much, and number of years used.

Tobacco product:
How much:
Years:

Do you drink alcohol? Yes No
Times per month:

Beer:

Wine:

Liquor:

Do you take any recreational drugs? Yes No

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:

Please print one copy of this page for your records, fax one copy to (734) 995-9318, and click the "Submit" button when finished.

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Disclaimer: The entire contents of this website are based upon the opinions of Dr. Arond-Thomas, unless otherwise noted. Individual articles are based upon the opinions of the respective author, who retains copyright as marked. The information on this website is not intended to replace a one-on-one relationship with a qualified health care professional and is not intended as medical advice. It is intended as a sharing of knowledge and information from the research and experience of Dr. Arond-Thomas and his community. Dr. Arond-Thomas encourages you to make your own health care decisions based upon your research and in partnership with a qualified health care professional.