patient history form

This form takes about 10 minutes to fill out. Do not feel obliged to be too detailed, but please do consider each section so that we do not miss significant pieces of your health history.

Personal Information
Name *
Name
Date of Birth *
Date of Birth
Phone *
Phone
Street Address
Street Address
(i.e. chief complaints)
Injuries & Dates
(tooth extractions, braces, etc.)
Hospitalizations & Surgeries
Medications
Include prescriptions, non-prescription meds, herbal remedies, vitamins, supplements, etc. Include dosage and frequency.
Allergies & Sensitivities
Include drugs, foods, chemicals, environmental
Illness & Treatment History
Please include dates & treatment.
Please include dates & treatment.
(sinus, mouth, throat, lungs) Please include dates & treatment.
Please include dates & treatment.
(stomach, liver, intestines, hernia) Please include dates & treatment.
(kidney, bladder) Please include dates & treatment.
(muscles, ligaments, bones, spine) Please include dates & treatment.
(rashes, dryness, lesions, moles) Please include dates & treatment.
Reproductive (female)
Reproductive (male)
PSA
Significant Events
Have you had any of the following?
Please check all that apply
Immunizations
Lifestyle
(how much, how often, # years)
(how much, how often, # years)
(name, how much, how often, # years)
(how much, how often, # years)
(eating habits, food allergies, cravings, preferences)
Family Medical History
(age or age when passed, diseases, conditions, traumas, allergies, significant life events)
(age or age when passed, diseases, conditions, traumas, allergies, significant life events)
(age or age when passed, diseases, conditions, traumas, allergies, significant life events)
(age or age when passed, diseases, conditions, allergies)