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 SS# 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

Emergency Contact

Name Relation Phone

Would you like us to communicate with you by Email

Confirm Email Address Signature

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

Confirm Signature

New Patient Questionnaire

Full name * Date of birth * Appointment Date Appointment Time Last Check-Up Last Completed Blood Test Provider List Medications List Vitamins List Please list all known medication allergies Please list all known food and environmental allergies Please list all surgeries, include dates Please list dates of any blood transfusions Apart from surgeries or childbirth, please list any hospitalizations

Social Background

What type of work do you do? With whom do you currently live? Do you have any children? Any cigarette, cigar or pipe use? Any alcohol use? Any recreational or other drug use, including cannabis?

Family Background

Please list date of birth and health status of you parents and any siblings. If deceased, please list their age(s) and the possible cause of death:

Mother Father Sisters Brothers Please check any of the following illnesses that have affected your family (include only parents, grandparents, and siblings):

General Review

Current Height Current Weight Are you on a special diet? Please describe your exercise habits 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? Do you have any issues with sleep?

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

General Head and Neck Lungs Do you have any history of the following: Heart Do you have any history of: Have you ever had any of the following: Abdomen Do you have a history of the following: Have you ever had the following: Muscular-Skeletal System Muscular-Skeletal System Do you have any history of the following: Endocrine Do you have a history of the following: Hematologic Neurologic Dermatologic Mood Do you have a history of the following Are there any other issues that you would like to discuss?

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? Do you have any lumps in your breasts? 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

Immunization Dates

Influenza Tetanus/Diphtheria (TD/DT) Measles, Mumps, Rubella (single or MMR) Hepatitis A & B (single or combo) Pneumovax-23 Polio Meningitis Typhoid Yellow Fever Zostavax Shingrix - Dose 1 Shingrix - Dose 2 Prevnar-13 Covid-19 - Dose 1 Covid-19 - Dose 2 Other Vaccines