Medical History Form

Patient Name

Date

Date of Birth

Reason for Visit

If Cancer is select: Specify Type

If Neurologic/Balance Issues is select, # of falls in the past 12 months:: Specify Type

Other: Please Specify

Past Surgeries

Skin Cancer

Basal Cell Carcinoma

Squamous Cell Carcinoma

Melanoma

Other Cancer

Type

Organ Transplant

Type

Joint Replacement

Type

Heart

Pacemaker/Defibrillator

Coronary Artery Bypass

Stent Placement

Valve Replacement

Other

Medications: Please list all medications you are currently taking including over the counter meds. You may also attach and give a list to the medical assistant.

Drug Allergies: Please list any allergies you have had to medications along with the type of reactions you may have had.

Have you had an inpatient stay in any hospital within the last 30 days?

Yes No

Do you have an advance directive or medical power of attorney?

Yes No

If so, who is named in these documents as your caregiver should you need to be cared for?

Height

Weight

Have you had flu vaccine this year?

Yes No

Date of vaccine?

Have you ever had a pneumonia vaccine?

Yes No

If so, when?

Have you had a COVID vaccine?

Yes No

If so, when and what type?

How much alcohol do you drink per day?

Do you currently smoke?

Yes No

If so, how much per day?

Do you feel safe at home

Yes No

Do you experience food insecurity, housing instability, transportation needs or utility difficulties

Yes No

Do you have a family history of skin cancer?

Yes No

If known, what type and which family member?

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.

Patient Signature

Date

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