Office of Dr. Kurth and Dr. Jones

Patient Demographics

First Name * Last Name * Middle Date of Birth Address Apt No City State Zip Home Phone Work Phone Cell Phone Other Phone Marital Status

Pharmacy Info

Pharmacy Name Pharmacy Phone Pharmacy Fax Pharmacy Address

Insurance Info ( Please Bring Insurance Card to Visit)

Insurance Name Policy Number Name of Primary Insurance Holder

Would you like us to communicate with you by Email

Confirm Email Address Signature

Receipt of Privacy Practices (HIPPA)

I have received a copy of Rebecca Kurth, MD's Notice of Privacy Practices

Confirm Signature

Patient Questionnaire

Full name * Date of birth * Appointment Date Appointment Time Provider List Medications List Vitamins List Please list all known medication allergies Please list all known food and environmental allergies Any surgeries since your last check-up? Any ER visits or hospitalizations since your last check-up? Any vaccines since your last visit here? Other concerns about your health?

Social Background

With whom do you currently live? Any changes in family structure? Any change in your work situation? Any cigarette, cigar or pipe use? Any alcohol use? Any recreational or other drug use, including cannabis?

Family Background

Please note any changes in health status of the following:

Mother Father Sisters Brothers Please note any other diseases that are in your family that you are concerned about.

General Review

Do you exercise regularly? Over the past year have you lost or gained weight? Are you happy with your current weight? To what do you attribute any change in weight? What is your exercise regiment? Do you have any issues with sleep?

Please check any of the following symptoms that you may be experiencing:

General Head and Neck Lungs Heart Abdomen Muscular-Skeletal System Muscular-Skeletal System Endocrine Neurologic Dermatologic Mood

Men - Urinary System

On average, how often at night do you get up to urinate? Have you consulted with a urologist this year? Have you had a PSA test in the past year? Do you have any concerns about your sexual functioning? Have you ever been treated for a sexually transmitted disease? Are you concerned about HIV risk? Have you ever been tested for HIV? Would you like to be tested today? Do you experience:

Women - Urinary System

On average, how often at night do you get up to urinate? Date of your last menstrual period? Are your cycles regular? Date of your last PAP smear? Have you ever been pregnant? Have you ever been treated for a sexually transmitted disease? Are you concerned about HIV risk? Have you ever been tested for HIV? Would you like to be tested today? Do you experience:

Travel

Do you have plans to travel outside of the US this year? If yes:

Exam Dates

Dental Exam Date Vision Screening Date Hearing Test Date Chest X-ray Date Colonoscopy Date Dermatology Exam Date Mammogram Date Bone Densitometry Date Stress Test Date Cholesterol Test Date