New Patient Form – aedoctors

Tina Bansal, MD
800 E Woodfield Rd, Ste 113. Schaumburg, IL 60173
Phone: 847-686-6866 Fax: 847-706-9891

Welcome to Advanced Endocrinology! We look forward to getting to know you!
The following questions are to
help us learn about your health history. Please fill the questions out to the best of your ability.

***IF YOU HAVE A PRINTED MEDICATION LIST, RECORDS OR RESULTS TO BE REVIEWED BY
THE PROVIDER PLEASE HAND THEM TO THE FRONT DESK STAFF, NOW***

Patient Name: Date of Birth(MM-DD-YYYY):

Assigned Birth Gender: Current Gender Identity:
Pronouns:

Primary Care Physician’s Name: Location:

Please list any other Doctors you see-
Please list their specialty and name:

Local Pharmacy: Location (Street/City):
Mail Order Pharmacy:

Check the lab you currently use for blood work:
  Other:

Personal Medical History:
Please Check if you have any of the following:

Other Condition(s) not listed above:

I am experiencing the following symptoms:

I have been experiencing these symptoms for:
These symptoms are:

My last tests for the above selected conditions were completed on (date). These tests
were drawn at:
Please Check correct location





Other Lab:

Do you have any allergies to any medications?

If yes, Please list the medication and reaction.

Medication Name: Allergic Reaction:
Medication Name: Allergic Reaction:
Medication Name: Allergic Reaction:
Medication Name: Allergic Reaction:

Social History:

What is you occupation? Do you currently smoke?
If yes, how long have you been smoking? Year(s)
How much do you smoke? Check which applies

A Day:

A Week:

Are you retired?
If yes, since when? (year)
What was your profession?

Are you on disability? YesNo
If yes, since when?(year)

If you don’t currently smoke, have you EVER smoked?

If yes, when did you quit?(Year)

Do you drink alcohol?

If yes, how many? Check one.


What is your current exercise level?

What is your marital status?

Do you have any children?
If yes, how many?

Surgical History:
Please list all the surgeries you have had in your lifetime with the name and date. (Incl.tonsillectomy, c-sections etc.)

Surgery Name:

Date of Surgery: (Month/Year)

Family Health History:

Please list any medical conditions of immediate family members below:

Mother:
Father:
Sister:
Brother:
Maternal Aunt:
Maternal Paternal Aunt:
Paternal Uncle:
Uncle:
Maternal Grandmother:
Paternal Grandmother:
Maternal Grandfather:
Paternal Grandfather:
Other:

Some Specific Diagnoses:

  • *Diabetes (type 1 or 2)

  • *Hypertension/High blood pressure

  • *Thyroid issues (underactive/ overactive/ enlarged)

  • *Pituitary issues (tumor or growth)

  • *Pancreatic problems

  • *High Calcium

  • *Parathyroid Issues

  • *Kidney Stones

  • * Osteoporosis

  • *Cancer (include the type)

Patient Name: Date(MM-DD-YYYY):

You may hand your personal medications list RATHER THAN fill this out.

Medication Name:

Dosage:

How do you take it?

Example:

Ranexa

500mg

One tab at breakfast, one tab at dinner.

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

Patient Name: Date(MM-DD-YYYY):

PATIENTS ON INSULIN ONLY

If blood sugar is:

Then I take:

Insulin Name:

EXAMPLE: 150 to 200

3

units

Novolog

to

units

to

units

to

units

to

units

to

units

to

units

to

units

Please check every time you use your sliding scale:

Before Breakfast,Before lunch,Before Dinner,Before Bed

In Addition to my sliding scale I take:

units for breakfast

units for lunch

units for dinner

Example:

4 units for breakfast, 3 units for lunch, 2 units for dinner

OR

I use a carb ratio of:

units for EACH grams of carbs