Minneapolis Health Clinic Patient Medical History Form

Appointments Request Registration Form
Patient Name *

First Name Last Name
Patient Gender *
Patient Birth Date *

Month Day Year
Patient Height (inches) *
Patient E-Mail *
Phone Number

Area Code Phone Number
Patient Weight (Ib) *
Reason for seeing the doctor: *
Patient Medical History
Please list any drug allergies
Do you have a primary care physician? Can you please write his/her name below and tell us which health system they belong to.
Have you ever had (Please check all that apply)

Anemia Asthma Arthritis Cancer Gout Diabetes Emotional Disorder Epilepsy Seizures Fainting Spells Gallstones Heart Disease Heart Attack Rheumatic Fever High Blood Pressure Digestive Problems Ulcerative Colitis Ulcer Disease Hepatitis Kidney Disease Liver Disease Sleep Apnea Use a C-PAP machine Thyroid Problems Tuberculosis Venereal Disease Neurological Disorders Bleeding Disorders Lung Disease Emphysema
Other illnesses:
Please list any Operations and Dates of Each
Please list your Current Medications
Healthy & Unhealthy Habits
Exercise

Never 1-2 days 3-4 days 5+ days
Eating following a diet

I have a loose diet I have a strict diet I don't have a diet plan
Alcohol Consumption

I don't drink 1-2 glasses/day 3-4 glasses/day 5+ glasses/day
Caffeine Consumption

I don't use caffeine 1-2 cups/day 3-4 cups/day 5+ cups/day
Include other comments regarding your Medical History
Do you smoke?

No 0-1 pack/day 1-2 packs/day 2+ packs/day
My signature below confirms that I assume financial responsibility of the services received from Minneapolis Health Clinic and will pay my medical bill in a timely manner. Payment will be needed on arrival.

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Appointments Request Registration Form

Patient Medical History

Healthy & Unhealthy Habits