Health History Form

If this is an emergency, call:

Patient Information

First Name:

Last Name:

Do you have any past medical history?

Yes No

If yes, please describe the reason for your visit

Please list the medications you are taking and for what conditions. Include the dosage and amounts.

Do you have any allergies to medications?

Do you Smoke?

Yes No

If Yes, how many packs a day and how many years?

Do you drink Alcohol?

Yes No

If Yes, how much?

Do you use recreational drug?

Yes No

If Yes, please describe

Has your family had a history of any of the following:
Check all that apply

If Other, please explain

Do you feel depressed?

Yes No

Do you have thoughts of hurting yourself or someone else?

Yes No

Do you currently have severe chest pain?

Yes No

Do you currently have shortness of breath?

Yes No

Do you currently have numbness or weakness in any body part?

Yes No

Do you have any additional symptoms aside from the initial reason for your visit?

FEMALES ONLY:

Is there a chance that you are pregnant?

Yes No

If so, are you experiencing vaginal bleeding?

Yes No

Your information will be encrypted.