(Note: This form is to be filled out by the patient and parent prior to seeing the physician. The physician should keep this form in the chart.)
Explain “Yes” answers below. Circle questions you don’t know the answers to
HEART HEALTH QUESTIONS ABOUT YOU
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
BONE AND JOINT QUESTIONS
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.
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.
Your information will be encrypted.