Note: This is a reference translation to help you understand a typical form. It is not an official document. Your provider's actual form may differ — always sign the provider's own version.
When you receive this formAt a new-patient appointment, or when establishing care with a new provider. Many clinics mail or email it before the visit so you can take your time completing it at home.
What to bring or have readyA list of your known diagnoses and surgeries with approximate dates; your family's medical history if you know it; and any previous medical records you have available.
Personal Information and Chief Complaint
English
What this field means
Full name
Your legal name as it appears on your ID or insurance card.
Date of birth
Used to verify your identity and match your records. Write in MM/DD/YYYY format if not pre-filled.
Reason for today's visit (chief complaint)
Describe the main symptom or concern in your own words — for example, 'knee pain for 2 weeks' or 'annual physical.' Keep it brief; the provider will ask follow-up questions.
Current Conditions and Diagnoses
English
What this field means
Known diagnoses (check all that apply)
Common options include diabetes, hypertension (high blood pressure), asthma, heart disease, cancer, thyroid disease, depression or anxiety, and arthritis. Check any you have been formally diagnosed with by a provider.
Current medications
List each prescription and over-the-counter medication you take regularly. Include the name and dose if known. A separate Medication and Allergy List form often captures this in more detail.
Ongoing symptoms or concerns
Note any symptoms that have persisted for weeks or months, even if you are not sure of the cause. This helps the provider decide which areas to examine or test.
Past Medical and Surgical History
English
What this field means
Past surgeries
List each surgery with the approximate year — for example, 'appendectomy, 2015.' If you have had no surgeries, write 'none.'
Previous hospitalizations
Include overnight hospital stays for any reason — illness, injury, or mental health — with the approximate year. Routine outpatient visits do not need to be listed here.
Significant illnesses or injuries
Include serious illnesses such as a heart attack, stroke, or major infection that required extended care, even if they did not result in surgery or hospitalization.
Family History
English
What this field means
Family history of heart disease, stroke, or cancer
Note which relatives were affected — for example, 'mother, breast cancer' or 'father, heart attack at age 50.' Focus on parents, siblings, and grandparents. If you do not know, write 'unknown.'
Family history of diabetes or inherited conditions
List conditions common in your family, such as type 2 diabetes, high cholesterol, kidney disease, or genetic disorders. Note which relative had the condition.
Social History
English
What this field means
Smoking status
Select: never smoked, former smoker (quit date if known), or current smoker (packs per day or type — cigarettes, e-cigarettes, cigars). Smoking affects many health conditions and medications.
Alcohol use
Indicate: none, occasional (a few drinks per month), moderate (up to one drink per day), or heavy (more than one drink per day). Alcohol interacts with many medications and affects health screenings.
Exercise habits
Select: sedentary (little to no regular exercise), light (1–2 days per week), moderate (3–4 days per week), or vigorous (5 or more days per week). Note the type of activity if you wish.