Medical History Form

Please fill out the text and check the appropriate box of your health information for electronic records

Please correct the errors described below.

Have you had any of the following done to evaluate the cause of your symptoms?

***IF POSSIBLE, WE WOULD GREATLY APPRECIATE YOU FAX TO OUR OFFICE ANY PERTINENT MEDICAL RECORDS IN ADVANCE, IMMEDIATELY AFTER YOUR VISIT, OR SIGN A RELEASE OF MEDICAL RECORDS FOR THEM. Fax: 305-598-0668

PAST MEDICAL ILLNESSES

ONCOLOGIC

INFECTIOUS DISEASE

FAMILY HISTORY

SOCIAL HISTORY

MEDICATIONS

Please be certain to include birth control pills, hormones, and ALL non-prescription medications, such as anti-inflammatories (i.e. aspirin, Advil, Motrin, Aleve, ibuprofen), acid blockers (i.e. Zantac, Pepcid, Tagamet, Prilosec OTC), topical hemorrhoid creams (i.e. Anusol, Preparation H), vitamins, and herbal supplements.

Medications

Dosage

Frequency

Add medication

REVIEW OF SYSTEMS

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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