Medical, Family, and Personal History Form

Patient Name*

First NameLast Name

Date of Birth*

How did you hear about TLC Family Health (if word of mouth, please include name)?*

Past Medical History (please list all significant medical problems you have had in the past, and include year of onset in parentheses):*

Include the following categories, if applicable: Cancer, cardiovascular, ear/nose/throat, endocrine, eyes, gastrointestinal, genitourinary, infections, lungs, muscle/bone/joint, neurological, psychiatric, skin, other

Are you up-to-date on your vaccines?*

YesNoUnsure

Please upload your vaccine record if you have one.

Past Surgical/Procedural History (please include year, name of surgeon, and city/state where it was performed):*

Are you allergic to any medicines?*

No known drug allergiesI have the following drug allergies (please include what specific reaction you had):

Medicines (both Prescription and Over-the-Counter) - please list all, including strength and frequency:*

Past Prescriptions (names only, and only include those you took regularly):*

Vitamins and supplements - please list all, including, if applicable, strength, amount, and frequency:*

Family History - please include any significant medical problems that your grandparents, parents, aunts, uncles, siblings, and children have or had (include who and age of onset in parentheses):*

Review of Systems

Do you currently have any symptoms within the following areas or systems? Elaborate as needed.

General (e.g., weight changes, fatigue, weakness)

Skin (e.g., rashes, itching)

Head/ears/eyes/nose/throat (e.g., headaches, blurry vistion, allergies, swollen glands)

Respiratory (e.g., cough, shortness of breath, wheezing, sputum)

Cardiac (e.g., chest pain, palpitations)

Gastrointestinal (e.g., heartburn, nausea, vomiting, rectal bleeding, diarrhea/constipation)

Urinary (e.g., increased frequency, burning, blood in urine)

Genital (e.g., discharge, pain, lumps, abnormal bleeding, STDs)

Musculoskeletal (e.g., muscle or joint pain)

Neurological (e.g., dizziness, fainting, numbness, pain, seizures)

Psychiatric (e.g., depression, anxiety)

Other

What is your marital status?*

*Please tell us the name of your spouse (and year married) or significant other, if applicable.

Please list the names (and dates of birth) of any children you have:

Occupation/Company or Grade/School*

Race and/or ethnicity*

Highest level of schooling:*

High schoolCollege or trade schoolPost-graduateOther

Religious Preference

Hobbies and interests

Tobacco Use*

Never smokedCurrent smoker*Former smoker**I only use smokeless tobacco***

*If current smoker, what year did you start smoking, and how many cigarettes do you smoke per day on average?

**If former smoker, please include the year you quit, how many years you smoked, and how many packs per day on average you smoked during that time.

***If you use smokeless tobacco, please describe the type and frequency of use.

How often do you drink alcohol?*

NeverRarely0-3 times per weekMost days of the week or every day

If/when you drink, how many drinks do you have?

1-23-56 or more

Describe any use of recreational drugs or drug abuse.*

NeverPast*Current*

*Please describe drug history.

Sexual orientation*

HeterosexualHomosexualBisexualOther*

*Please describe

Briefly describe caffeine use. Type "None" if applicable.*

Have you ever been sexually active?*

Briefly describe your diet and eating habits.*

What type of exercise do you do, how often, and for how long? Type "None" if applicable.*

Briefly describe your sleeping habits.*

Please list the types and names of any pets you have.

If you have one, please upload a recent photo (head shot preferable, but not necessary) of yourself.

What else would you like us to know about you, health or otherwise?

TLC Family Health
Disclosure and Consent
General Patient Authorization

I hereby authorize the medical team at TLC Family Health to render health care to me according to the best judgment and orders of the physician.*

YesNo

I understand that payment for my visit or other services is due on the day of service (payment is made through the Hint Health payment management system, using the payment method on file). Payment methods that have expired must be rectified before any other services will be provided.*

YesNo

I have carefully read and agree to the TLC Family Health Patient Agreement (link below).*

YesNo

TLC Family Health Patient Agreement

If a Medicare patient, I will carefully review and complete the Medicare Private Contract (link below)*

YesNoN/A

Medicare Private Contract (Dr. Braswell)

Medicare Private Contract (Dr. Cluff)

I authorize TLC Family Health to release my medical information pertaining to my diagnosis and/or treatment, including but not limited to, information concerning communicable diseases such as Human Immunodeficiency Virus ("HIV"), laboratory test results, medical history, treatment, or any other such related information to:

1) Representatives of local, state or federal agencies in accordance with law*

YesNo

2) Employees and representatives of TLC Family Health for investigation and defense of any claim or cause of action, actual or potential, which is or may be asserted against TLC Family Health, or any affiliate of TLC Family Health*

YesNo

3) Any health care providers associated with my care to facilitate further treatment*

YesNo

I authorize TLC Family Health to disclose medical information pertaining to my diagnosis and/or treatment, laboratory test results, medical history, immunization records, or any other such related information to those listed below (e.g.: Referring Physician, Specialists, Mother, Father, Spouse, Children, etc.).*

Yes. Please include name(s), relationship, phone number, and comments, if desired.I do not wish to have my medical information shared with anyone.

OK to disclose to:

Signature of Patient or Legally Authorized Representative*

Relationship:*