Patient Health History

Please correct the errors described below.

History of Present illness

Where is the pain / problem?
Example: Normal vs Abnormal Color, Activity, etc.
(How severe is the pain/problem on a scale of 1-10 with 10 being the most severe?)
(How long have you had this pain / problem? When did it start?)
(Does the pain/problem occur at a specific time?)
(Where were you at the onset of this pain/problem?)
(What other associated problems have you been having?)
(What makes the pain/problem worse or better? Have you had previous episodes?)

Past Medical History

(Have you ever had the following: (circle "yes" or "no" / leave blank if you are uncertain.)

Previous Hospitalizations / Surgeries / Serious Illnesses

Add Additional Hospitalizations

Patient Social History

Excessive Exposure

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.

Family Medical History

Add Additional Siblings

Indicate which of the below you have experienced in the last 1-2 months
1 = Never; 2 = Rarely; 3 = Occasionally; 4 = Frequently; 5 = Constantly

Eyes / Ears / Nose / Throat / Respiratory

Muscular / Skeletal

Neurological

General

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor's office of any changes in my medical status. I also authorize the healthcare staff to perform the necessary services I may need.

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.

Doctor's Review

Your information will be encrypted.

Loading...