Cooley Dickinson Medical Group Geriatrics New Patient Information Form - Welcome to Cooley Dickinson Medical Group Geriatrics

When? □ COPD □ Dementia / Alzheimer’s Disease □ Bronchitis □ Parkinson’s Disease HEART PROBLEMS BONE & JOINT PROBLEMS □ Heart attack. [...] When? □ Arthritis □ Heart failure □ Osteoporosis □ High blood pressure □ Fractured hip, wrist, spine (circle). [...] When: □ Irregular heart beats / arrhythmias □ Gout 2 Past Medical History (continued) GASTROINTESTINAL PROBLEMS OTHER HEALTH PROBLEMS □ Ulcers □ Anemia □ Heartburn □ Hernia □ Diverticulitis □ Thrombosis (blood clots) □ Liver disease / cirrhosis □ Cancer. [...] Where? □ Hepatitis □ Depression □ Polyps □ Sexual problems □ Gallbladder disease □ Other, specify: GLAND PROBLEMS □ Diabetes □ Thyroid Disease List surgeries (operations). [...] Who? How many children do you have? Are you in regular contact with your children? □ Yes □ No Do you drink alcohol, including beer and wine, Have you ever smoked cigarettes? or other alcohol (such as vodka, whiskey, gin)? □ Yes □ No □ Daily If currently smoking: How much □ Almost daily (4 to 6 times a week) do you smoke? ___________packs per day □ 1 to 3 times a week If no longer smoking: How much.