Patient History
After you select the name of the provider you are scheduled to see, the health form will be displayed.
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My provider is not in the list
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
Patient Information
*
Please provide your full legal name as it appears on your driver's license, state identification card, or government issued identification card.
Birth Month
January
February
March
April
May
June
July
August
September
October
November
December
Birth Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
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27
28
29
30
31
Birth Year
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
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1964
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1962
1961
1960
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1958
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1956
1955
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1951
1950
1949
1948
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1945
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1943
1942
1941
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1939
1938
1937
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1935
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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
Gender
Male
Female
Patient History
* Required Information
Tobacco Use
*
What is your current cigarette smoking status?
Current (every day)
Current (some days)
Previous
Never
*
How many packs per day do you smoke?
*
How many packs per day did you smoke?
<1
1
1.5
2
2.5
3
3.5
4
4+
*
How many years have you been smoking?
*
How many years did you smoke?
<1
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
30+
*
Do any of these statements apply to you?
I would like to quit
I have never tried to quit
I have tried, unsuccessfully, in the past, to quit
*
Please mark any tobacco products that you use:
Pipe
Snuff
Cigars
Chewing tobacco
None
*
Are you exposed to secondhand smoke?
No
Minimally
Frequently
Daily
Alcohol Use
*
How often do you drink alcohol?
Never
Moderately
Quit recently
Occasionally
Heavily
Quit a long time ago
*
Type(s):
Beer
Wine
Liquor
Drug Use
*
Do you have a dependency or addiction to drugs now or in the past?
Yes
No
*
which one's?
Amphetamines
Barbiturates
Cocaine
Codeine
Diazepam
Heroin
Hydrocodone
Marijuana
Morphine
Oxycodone
Soma
*
Do you use recreational drugs?
Yes
No
*
which one's?
Amphetamines
Barbiturates
Cocaine
Codeine
Diazepam
Heroin
Hydrocodone
Marijuana
Morphine
Oxycodone
Soma
Caffeine Use
*
Do you consume any of these?
Carbonated beverages
Tea
Coffee
Chocolate
None
*
Servings per day:
none
1
2
3
4
5
6
7
8
8+
Exercise
*
Number of times you exercise each week:
none
1
2
3
4
5
6
daily
*
Type(s):
Walking
Yoga
Team Sports
Running
Stretching
Yardwork
Cycling
Exercise classes
Housework
About You
*
Home Living Setting
Alone
Spouse
Children
Nursing Home
Mother
Father
Assisted Living
Other
*
Are you retired?
Yes
No
*
What is your current or most recent occupation?
*
What is your dominant hand?
Right
Left
Neither
Transfusions
*
Will you accept transfusion of blood products?
Yes
No
Past Medical History
*
Please indicate if YOU have a history of the following:
AFib
Alcohol Abuse
Anemia
Anxiety Disorder
Arthritis
Asthma
Blood Clots
Bone Cancer
Breast Cancer
COPD
Depression
Diabetes
Drug Addiction
Epilepsy
Fibromyalgia
GI Bleed
Gout
Heart Disease
Hepatitis
HIV
High Cholesterol
High Blood Pressure
Hypothyroidism
Infectious Mononucleosis
Kidney Disease
Liver Disease
Lung Cancer
Lymphoma
MRSA/Staph Infection
Mitral Valve Prolapse
Multiple Myeloma
Osteoarthritis
Osteoporosis
Pacemaker
Peripheral Vascular Disease
Peripheral Neuropathy
Prostate Cancer
Prostate Enlarged
Recurrent UTIs
Reflux
Rheumatoid Arthritis
Renal Failure
Sleep Apnea
Stomach Ulcer
Stroke
Thyroid Dysfunction
Tuberculosis
NONE of the Above
Family Medical History
*
Please indicate which family members have had these illnesses:
FAMILY HISTORY UNKNOWN
NO SIGNIFICANT FAMILY MEDICAL HISTORY
Problems with Anesthesia
Father
Mother
Brother
Sister
Son
Daughter
Cancer
Father
Mother
Brother
Sister
Son
Daughter
Leukemia
Father
Mother
Brother
Sister
Son
Daughter
Heart Disease
Father
Mother
Brother
Sister
Son
Daughter
High Blood Pressure
Father
Mother
Brother
Sister
Son
Daughter
Arthritis
Father
Mother
Brother
Sister
Son
Daughter
Stroke
Father
Mother
Brother
Sister
Son
Daughter
Diabetes
Father
Mother
Brother
Sister
Son
Daughter
Bleeding/Clotting Problem
Father
Mother
Brother
Sister
Son
Daughter
Current Symptoms
Please select only the symptoms you CURRENTLY are experiencing.
Select all that apply - if no symptoms, please select 'NONE'
*
General
Fever
Sleeping problems
Unintentional weight gain
None
*
Eyes
Blurred vision
Double vision
Loss of vision
None
*
Ear, Nose, and Throat
Hearing loss
Dizziness
Ringing in the ears
Hoarseness or other voice changes
Snoring
Sore throat
Sores in mouth
Partials or Dentures
None
*
Cardiovascular
Bluish discoloration of lips or fingernails
Blacking out or fainting
Chest pain
Heart murmur
Irregular heartbeats
Leg cramps when walking
Swelling of ankles
None
*
Respiratory
Non-productive cough
Productive cough
Shortness of breath
None
*
Gastrointestinal
Abdominal pain
Diarrhea
Heartburn
Nausea
Vomiting
None
*
Musculoskeletal
Pain in back
Pain in neck
Painful in joints
Stiffness in joints
Stiffness in neck
Swelling of joints
None
*
Neurologic
Changes in alertness
Headaches
Loss of bladder control
Loss of consciousness
Numbness
Seizures
Tingling
Weakness
None
*
Endocrine
Fatigue
Cold feeling
Appetite is increased
Feel hot when others do not
None
*
Heme / Lymphatic
Bleeds excessively after injury
Bruises easily
Masses (lumps) in armpit
Masses (lumps) in neck
Masses (lumps) in groin
None
*
Allergic / Immunologic
Food intolerances
Hives
Reaction to insect bites
None
Allergies
*
Are you allergic to any of the following?
No Allergies
Adhesive tape
Iodine
Latex
Metal
Seafood
Surgeries and Hospitalizations
*
Have you ever had any problems with anesthesia (being numbed or put to sleep)?
Yes
No
*
Have you had any surgeries?
Yes
No
*
Please select how many surgeries you have had, and put in the name of the procedure and the year it was performed.
1
2
3
4
5
6
*
Have you ever been hospitalized?
Yes
No
*
Please select how many times you have been hospitalized, and the reason why as well as year.
1
2
3
4
5
6
Physician / Pharmacy info
*
Name of Primary Care Physician
*
Pharmacy Preference (include location)
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