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Patient History
After you select the name of the provider you are scheduled to see, the health form will be displayed.
Please select the name of the doctor you are scheduled to see.
My provider is not in the list
---------- Date of Birth ----------
First Name
Last Name
Month
Day
Year
Gender
January
February
March
April
May
June
July
August
September
October
November
December
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Male
Female
Your provider is not in the list of providers above. You will need to notify the clinic that your provider is not in the list.
In order to notify the clinic, please enter your name and other demographic information above and enter the name
of your provider below. The clinic will be notified that the provider's name is missing.
Provider Name
PAST MEDICAL HISTORY
Please indicate if YOU have a history of the following:
Anemia
Current
Past
Appendicitis
Current
Past
Arthritis
Current
Past
Asthma
Current
Past
Bladder Infection
Current
Past
Cancer
Current
Past
Congestive Heart Failure
Current
Past
COPD
Current
Past
Deep Vein Thrombosis (DVT)
Current
Past
Diabetes (Type 2 Adult Onset)
Current
Past
Insulin Dependent
Current
Past
Emphysema
Current
Past
Esophagitis
Current
Past
Gallbladder Problems
Current
Past
Glaucoma
Current
Past
Head Injury
Current
Past
Heart Attack
Current
Past
Heart Murmur
Current
Past
Heart Palpitations
Current
Past
Hepatitis
Current
Past
Hernia
Current
Past
High Blood Pressure
Current
Past
Phlebitis (Vein Swelling)
Current
Past
Pleurisy
Current
Past
Pneumonia
Current
Past
Rheumatic Fever
Current
Past
Stroke
Current
Past
Thyroid Problems
Current
Past
Tuberculosis
Current
Past
Ulcers
Current
Past
Urinary Tract Infection (UTI)
Current
Past
HIV
Current
Other Disease or Significant Medical Illness (please specify):
NONE
SURGICAL HISTORY
Please select all surgeries you have had:
Ankle
Deviated Septum Repair
Hysterectomy
Adenoidectomy
Ear Tubes
Knee Replacement
Appendectomy
Elbow
Lumbar Vertebral Fusion
Arthroscopy Knee
Eye
Lumpectomy
Back
Foot
Rotator Cuff Repair
Breast
Gallbladder
Shoulder
Carpal Tunnel
Gastric
Thyroid
Cataract
Heart Stent
Tonsillectomy
Cath Stent Placement
Hemorrhoidectomy
Tubal Ligation
Cervical Vertebral Fusion
Hernia Repair
Vein Stripping
Cesarean Section
Hip
Wrist
Coronary Artery Bypass
Hip Replacement
Other Surgery (please specify):
NONE
ALLERGIES
Are you allergic to any drugs / medications?
Aspirin
Codeine
Morphine
NSAIDS (ibuprofen, naproxen, etc.)
Penicillin
Sulfa
Other (please specify):
NONE
Are you allergic to any environmental allergens?
Animal Dander
Bee Stings
Eggs
Food Dye
Latex
Mold
Nuts
Pollen
Shellfish
Other (please specify):
NONE
FAMILY MEDICAL HISTORY
Please indicate which family member(s) have had these illnesses:
Family History UNKNOWN
ADOPTED
Father
Mother
Grandmother
Mother's
side
Grandfather
Mother's
side
Grandmother
Father's
side
Grandfather
Father's
side
Brother
Sister
Arthritis
Blood / Clotting Disorders
Cancer
Type 2 Diabetes
Heart Disease
Kidney Disease
Rheumatoid Arthritis
Stroke
Your Mother is:
living
deceased
age and cause of death:
Your Father is:
living
deceased
age and cause of death:
NONE
SOCIAL HISTORY
ALCOHOL USE
Do you drink alcoholic beverages?
yes
no
social drinker
How many drinks per week?
7 or less
8-14
15 or more
TOBACCO USE
Smoking status:
never
previous
current (some days)
current (everyday)
How many packs per day do you (or did you) smoke?
less than 1
1-2
more than 2
How many years have you (or did you) smoke?
less than 1
1-5
6-10
11-15
16-20
21+
MARITAL STATUS
single
currently married
divorced
widow / widower
WORK HISTORY
Occupation:
office worker
homemaker
outdoor worker
retired
Other (please specify):
RACE
Native American
African American
Caucasian
prefer not to answer
Other (please specify):
LANGUAGE
English
Spanish
prefer not to answer
Other (please specify):
ETHNICITY
Hispanic or Latino
Non-Hispanic or Latino
prefer not to answer
OTHER
Any person, family or job problem(s) that might affect your situation / recovery?
no
yes
please specify:
Would you like a copy of your clinical summary when you check out?
no
yes
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