Health Questionnaire
Columbus
Patient Name
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First Name
Last Name
Personal Pronouns
Date of Birth
*
Sexual Orientation & Gender Identity
Sexual Orientation
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Straight
Gay/Lesbian
Bisexual
Prefer not to disclose
Don't know
Gender Identity
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Male
Female
Trans Male
Trans Female
Non-binary
Don't Know
Prefer not to disclose
Overall Health Status
How would you describe your current health?
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Excellent
Good
Fair
Poor
Significant Illnesses
Pleas list any significant illnesses you have had in the space below. If you don't have enough room, you can upload a list in the following formats:pdf, doc, docx, xls, xlsx, csv, txt,
Significant Illnesses
*
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Past Surgeries
Please list any past surgeries you have had in the space below.If you don't have enough room, you can upload a list in the following formats:pdf, doc, docx, xls, xlsx, csv, txt,
Please list any past surgeries you have had.
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Allergies
What kind of allergies do you have?
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Food
Medicine
Please list any food allergies you have. If you don't have enough room, you can upload a list in the following formats:pdf, doc, docx, xls, xlsx, csv, txt,
*
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Please list any medication allergies you have. If you don't have enough room, you can upload a list in the following formats:pdf, doc, docx, xls, xlsx, csv, txt,
*
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Please describe the symptoms you experience when you have an allergic reaction.
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Preferred Facilities
If labs or x-rays are needed, what facility do you prefer?
Name of preferred lab
*
Name of preferred x-ray facility
*
Preferred Pharmacy
Name of Preferred Pharmacy
*
Preferred Pharmacy Location
*
Family History
Has a blood relative had any of the following conditions? Please check all that apply.
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Alcohol
Anemia
Arthritis
Asthma
Bleeds Easily
Cancer
Diabetes
Emphysema
Epilepsy
Glaucoma
Hay Fever
Heart Disease
Hepatitis
High Blood Pressure
High Cholesterol
Kidney Disease
Mental Illness
Migraines
Osteoporosis
Stomach Problems
Stroke
Thyroid
Tuberculosis
Your Medical History
Have you had any of the following conditions? Please check all that apply.
Alcohol
Anemia
Arthritis
Asthma
Bleeds Easily
Cancer
Diabetes
Emphysema
Epilepsy
Glaucoma
Hay Fever
Heart Disease
Hepatitis
High Blood Pressure
High Cholesterol
Kidney Disease
Mental Illness
Migraines
Osteoporosis
Stomach Problems
Stroke
Thyroid
Tuberculosis
Medication List
Please list the prescription medications you currently take. If you don't have enough room, you can upload a list in the following formats:pdf, doc, docx, xls, xlsx, csv, txt,
1) Medication Name
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1) Dose
*
1) Prescribing Physician
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2) Medication Name
2) Dose
2) Prescribing Physician
3) Medication Name
3) Dose
3) Prescribing Physician
4) Medication Name
4) Dose
4) Prescribing Physician
5) Medication Name
5) Dose
5) Prescribing Physician
6) Medication Name
6) Dose
6) Prescribing Physician
7) Medication Name
7) Dose
7) Prescribing Physician
8) Medication Name
8) Dose
8) Prescribing Physician
9) Medication Name
9) Dose
9) Prescribing Physician
10) Medication Name
10) Dose
10) Prescribing Physician
Upload a List of Meds, Doses, and Prescribing doctors
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Consent
I give my consent for Centerstone Health Services to use and disclose my protected health information (PHI) for treatment,payment, and health care options (TPO). I have received a copy of the NPP. The Clinic may mail to my home or otheralternative location any items that assist the practice in carrying out TPO, such as appointment reminders, patient statements,insurance items, and any calls pertaining to my clinical care, including test results. I have the right to request the Clinic torestrict how it uses or discloses my PHI, however, the practice is not required to agree to my restrictions.
Please write your signature below with your finger or mouse.
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Date Signed
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Month
-
Day
Year
Date
Please verify that you are human
*
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