Health History

Please correct the errors described below.

In the past 2 weeks, have you been bothered by:

Review of Symptoms: Please choose any persistent symptoms you have had the past few months. Read through every section and choose “No problems” if none of the symptoms apply to you.


Personal Information:

Emergency Contact:

Pharmacy Information:

Advanced Directive:

I / we do hereby consent to and authorize the performance of all treatments, surgeries and medical services deemed advisable by the physicians and staff of Langer Family Medicine, PA to me or to the above-named minor of whom I am the parent or legal guardian. I hereby certify that to the best of my knowledge, all statements contained hereon are true. I understand that I am directly responsible for all charges incurred for medical services for myself and my dependents regardless of insurance coverage. I furthermore agree to pay legal interest, collection expenses, and attorneys’ fees incurred to collect any amount I may owe. I also hereby authorize Langer Family Medicine, PA to release information requested by insurance companies and / or its representatives. I fully understand this agreement and consent will continue until canceled by me in writing. 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


List all medications you are currently taking, including both prescription and non-prescription, and the dosage.

Add new medication

Medication Allergies:

Medical History:

List if you have ever experienced specific illnesses/chronic medical conditions, and the year of onset.

Add Illness / Chronic Medical Condition

Surgical History:

List any surgeries you have had, and the year preformed.

Add Surgical Procedure

GYN History:

Date and Type of Delivery:

Add new row

Health Maintenance:

Choose below if you have received the following, and the date of most recent exam.

Family History:

Choose all that apply, and list family member affected.

Social History:

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