Health History Update Form

PATIENT INFORMATION

Name:

Date of Birth:

Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

Work Phone:

Preferred method of contact:

Home

Cell

Work

No Preference

Email:

Patient Employer/School:

Emergency Contact:

Relationship

Phone:

Insurance Information:

Has your insurance changed within the last six months?

Yes No

MEDICAL HISTORY

Are you:

Pregnant Nursing

# Weeks pregnant:

Current medications (please list all below):

Add another medication

Allergies (please list all below):

Add another allergy

Artificial Joints - Date of surgery:

Blood Disease/Disorder - Explain:

Cancer - Type:

Cancer - Date Diagnosed:

Diabetes Type:

Diabetes - Controlled?

Yes No

Heart Problems - Explain:

Hepatitis - Type:

Radiation Therapy - Date:

Venereal Disease - Type:

Recent surgeries:

Other conditions not specified:

Do you currently drink alcohol?

Yes No

If so, # drinks/week

Do you currently smoke or use smokeless tobacco?

Yes No

If so, for how long?

# Packs/Day:

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

Signature of Patient

Date

Dr. Initial

Your information will be encrypted.