New Patient Medical History

PATIENT MEDICAL HISTORY

Patient Last Name

First & Middle Name

Date of Birth

Age

Gender

Height

Weight

Parent or Guardian Name

Cell Phone

Home Phone

Email Address

Physical Street Address

Physical City, State and Zip Code

Mailing Address if Different than Physical Address Such as a P.O. Box

Emergency Contact Name

Emergency Contact Phone

Occupation

Primary Care Physician Name

Primary Care Physician Phone

Referring Physician Name

Referring Physician Phone

Pharmacy

Pharmacy Phone

Have you traveled abroad within the last 3 months?

Yes

CHIEF COMPLAINT

What is the reason for your visit and medical treatment(s) used for symptoms?

Include: Is this a recurrent issue? If so, when did the issue(s) begin and how often do they occur?

HEALTH HISTORY

List any prior major illnesses or injuries.

If none, type NONE.

List surgeries and hospitalizations. Include any complications and year they occurred.

Bleeding or anesthesia complications etc. If none, type NONE.

List any allergies to medications, anesthetics or materials. Include reactions.

Hives, rash, nausea, anaphylaxis etc. If none, type NONE.

List of Medications. Include reason for taking.

Include all over the counter medications/vitamins. If none, type NONE.

FAMILY HISTORY

List any other significant family history below.

Cancer, diabetes, heart disease, high blood pressure etc.

SOCIAL HISTORY

List type of drug(s) used.

Patient Signature

Leave blank. You will sign during your visit.

Today's Date

Physician Signature

Today's Date

DOCUMENTS : We will scan at time of visit if you are unable to upload documents. You must bring your insurance cards and identification with you to your appointment.

Insurance Card Front

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Insurance Card Back

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Referral/Insurance Approval

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Imaging and/or Reports

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