The Sievering Surgical Clinic

Sieveringer St 9, 1190 Vienna Tel: 328 8777

Medical History -

New Patient Questionnaire

Serving our community

Welcome to the Sievering Clinic in Vienna

Medical History

As a new patient, you have a lot of background to share with us. Use this template when you are visiting  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.

IMPORTANT TIP: The information you entered is not saved to protect your privacy. Please print this page after entering the data so you don't lose your information.

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
    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: 

    To avoid errors, bring in any medications your child takes in their original bottles.

    Tip: Only 5 lines available, so summarize.

    IMPORTANT TIP: The information you entered is not saved to protect your privacy. Please print this page now so you don't lose your information.

    | 15.05.2006 | Read more | Print |

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