Patient Medical History Form

Appointment Request Form

If you do not hear from us in 1 business day, please call our office at: (763)496-5708
Patient Name*

First NameLast Name
Patient Sex assigned at birth*
Patient Birth Date*

MonthDayYear
Height (Feet and inches)*
E-Mail Address*
Phone Number*
Phone Number

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Ethnicity
Patient Weight (Ib)*
How did you hear about Minneapolis Health Clinic?*
Do you have health insurance?*

YesNo
Insurance Company Name*
Please upload a photo of your insurance card here:

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Reason for visit:*
Reason for Visit*

Yearly Wellness ExamVisit for Health ConcernImmigration ExamPre Operative VisitMental Health Evaluation and ReferralTB Testing for Employment
Upload photo of the order your employer has given you. We will not schedule this appointment without a proper order.*

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When was your last wellness exam?
What health concerns do you have?*
What is the name of your law firm? (If needing an immigration exam)
Surgeon Name:
Surgery or Procedure being performed and date
Fax number to send pre operative evaluation to:
Patient Medical History
Primary Care Physician and and Clinic Name:*
Please list any drug allergies*
Please list your Current Medications*
Have you ever had (Please check all that apply)*

AnemiaADD/ADHDAnxietyAsthmaArthritisBipolar DisorderCancerGoutDiabetesDepressionEpilepsy SeizuresFainting SpellsEmphysemaGallstonesHeart DiseaseHeart AttackRheumatic FeverHigh Blood PressureDigestive ProblemsUlcerative ColitisPeptic Ulcer DiseaseHepatitisKidney DiseaseLiver DiseaseSleep ApneaUse a C-PAP machineThyroid ProblemsTuberculosisVenereal DiseaseNeurological DisordersBleeding DisordersLung DiseaseNone
Please list any Operations and Dates of Each*
Other illnesses:
Lifestyle Habits
Occupation*
Marital Status*

SingleMarriedSeperatedDivorced
Do you smoke or use tobacco products*

NoOccasionally0-1 pack/day1-2 packs/day2+ packs/day
Alcohol Consumption*

I don't drinkOccasionally (less than monthy)A few times a monthA few times a week1-2 drinks/day3-4 drinks/day5+ drinks/day
Caffeine Consumption*

I don't use caffeineOccasionallyA few times a monthA few times a week1-2 cups/day3-4 cups/day5+ cups/day
Do you use any recreational drugs? *
Any particular diet you follow?*

I have a well-rounded, healthy dietI have a modified diet/diet planI don't have a particular diet plan
Exercise*

Never1-2 days3-4 days5+ days
Are you sexually active? If so gender of you partner(S).*
Please list any family medical history.
Include other comments regarding your Medical History
Are you interested in any other services?

Internal medicine consultationImmigration examIV vitamin infusionsWeight loss consultationLipocel body contouringAesthetics- Botox, dysport, fillersMedical marijuana consult for chronic pain and other indicated conditions
My signature below confirms that I assume financial responsibility of the services received from Minneapolis Health Clinic and understand that it is my responsibility to understand my insurance benefits (if applicable). Minneapolis Health Clinic is not responsible for checking these benefits for me. A complete financial agreement will be included in my intake paperwork at the time of my appointment.*

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Please upload your medical insurance card if you have one

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Should be Empty:

Appointment Request Form

Patient Medical History

Lifestyle Habits