[HEALTH] Patient Medical History & Questionnaire

New patient intake - please complete the following. [ENTER ORGANIZATION NAME, ADDRESS] Phone: (123) 456-6789 Email: YourName@YourEmail.com Website: YourWebsite.com

Welcome to our clinic!
Our Location
Patient name First Last
Date of birth / MM / DD YYYY
Sex
Male Female
Age
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Marital status
Single Married Divorced Widowed
Home phone - ### - ### ####
Cell phone - ### - ### ####
Email
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Confirm Email *
Address
Address Type Street Address Address Line 2 Apartment City State / Province / Region Postal / Zip Code Country
Occupation
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Employer
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Work phone - ### - ### ####
for CHILD patients (if applicable)

If the patient is a child, please complete the following
Mother's Name First Last
Mother's Employer
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Mother's Telephone - ### - ### ####
Father's Name First Last
Father's Employer
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Father's Telephone - ### - ### ####
Medical History

Please answer each question as accurately as possible
Have you been under the care of a medical doctor during the past two years?
Yes No
If yes, for what?
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Physician's name
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Physician's phone number - ### - ### ####
Have you taken any medication or drugs during the past two years?
Yes No
Are you taking any medication, drugs or pills now?
Yes No
If yes, please list the name and dosage
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Are you aware of having an allergic (or adverse) reaction to any medication or substance?
Yes No
If yes, please list
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Have you been hospitalized in the past five years?
Yes No
Indicate which of the following you have had, or presently have
Heart (Surgery, Disease, Attack) Chest Pain Congenital Heart Disease Heart Murmur High Blood Pressure Artificial Heart Valve Mitral Valve Prolapse Heart Peacemaker Rheumatic Fever Arthritis / Rheumatism Cortisone Medicine Swollen Ankles Stroke Diet (Special / Restricted) Artificial Joints (hip, knee etc.) Kidney Trouble Latex Sensitivity Stomach Ulcers Diabetes Thyroid Problems Glaucoma Emphysema Chronic Cough Tuberculosis Asthma Hay Fever Allergies or Hives Sinus Trouble Radiation Therapy Chemotherapy Tumors Do You Smoke Hepatitis Liver Disease Yellow Jaundice Venereal Disease A.I.D.S. H.I.V. Positive Cold Sores / Fever Blisters Blood Transfusion Hemophilia Sickle Cell Disease Bruise Easily Neurological Disorders Epilepsy or Seizures Fainting or Dizzy Spells Nervous / Anxious Psychiatric / Psychological Care
Do you have, or have you had any disease, or problem not listed?
Yes No
If yes, please list
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Women:
	Yes	No
Are you pregnant?
Nursing?
Taking birth control pills?

I understand the above information is necessary to provide me with medical care in a safe efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the representative health care provider or agency, who may release such information to you. I will notify the doctor of any change in my health or medication.

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[HEALTH] Patient Medical History & Questionnaire

[HEALTH] Patient Medical History & Questionnaire

for CHILD patients (if applicable)

Medical History