CBFP Adult Medical History Form

Welcome!

It is our sincere desire to provide you with quality, comprehensive health care. It is important we gather a detailed picture of your health and health related issues. Please complete this form thoroughly, legibly and accurately. The privacy of your health information will become a legally protected part of your medical record. Thank you.
About You
Your Full Name*

First NameLast Name
Any nicknames you prefer to go by?
Your Date of Birth*
MM/DD/YYYY
Gender*

MaleFemaleOther
State or Country of Birth*
Any Special Communication Needs?
Such as hearing impairment, blindness, English learner or other needs
Race / Ethnicity*

White / CaucasianBlack / African AmericanHispanic / LatinxAsian / Pacific IslanderAmerican Indian / Alaska NativeDecline to sayOther
Language*
Are you a veteran?*

YesNo
Are you an organ donor?*

YesNo
I am:*

Right-handedLeft-handed
Marital Status*

SingleMarriedSeparatedDivorcedWidowedDomestic PartnershipOther
Spouse Name
Parent or Legal Guardian (for patients under 18)

First NameLast Name
Occupation
Employer
Contact Information
Mailing/Street Address*

Street Address

Street Address Line 2

CityState

Zip Code
Best Phone Number:*

Area CodePhone Number
This is my:*

Home PhoneCell PhoneWork PhoneOther
May we leave a detailed message on this primary phone number?*

YesNo
Secondary Phone Number:
(XXX) XXX-XXXX
Your E-Mail Address*
example@example.com
Communication Preferences

Please share with us your emergency contacts as well as any additional people with whom we can communicate about your health if necessary. Use the "+" button to add additional rows.
Emergency Contacts:*
I hereby authorize Doylestown Healthcare Partnership to discuss and or release my PHI (protected health information) to:*
I hereby authorize Doylestown Healthcare Partnership to discuss and or release my PHI (protected health information) to:*
Do you have an Advance Directive or Living Will?*

YesNo
Have you designated a Durable Power of Attorney?*

YesNo
Please enter information below for your Power of Attorney:*
Medical Conditions & History
Do you see any specialists?*

YesNo
Please list your specialists:*

Adult Vaccination/Immunization History:*

	No	Yes	Vaccine Date(s) and Details:
Tetanus
Zoster
Prevnar 13
TDAP
Shingrix
Pneumovax 23
COVID-19 Vaccine (include brand)
COVID-19 Booster (include brand)

Have you ever been diagnosed with any of the following:*

CancerAutoimmune DiseaseSkin DiseaseSTDMeasles/ MumpsMultiple SclerosisGoutTuberculosisHepatitisThyroid DisorderSeizures / EpilepsyBone/Joint DisorderChicken PoxArthritisParkinson’s DiseaseGlaucomaPneumoniaEye DiseaseAsthmaSeasonal AllergiesRheumatic FeverScarlet FeverEmphysema / COPDPolioPancreatitisStrokeKidney DiseaseKidney StoneBleeding DisorderLyme DiseaseHeart Disease / CADHeart MurmurPulmonary ClottingHeart AttackHigh Blood PressurePeripheral Vascular DiseaseHeart FailureReflux DiseaseGall BladderHigh CholesterolBlood ClotIrritable BowelStomach UlcerDiverticulitisErectile DysfunctionPsychiatric CareDepressionAnxietyDiabetesProstate DiseaseUrinary DisordersEating DisorderBreast LumpVaginal InfectionMenstrual ProblemsReproductive IssuesColitisSexual DysfunctionSleep ApneaAnemiaLiver DiseaseDrug AddictionAlcoholismMigraines/HeadacheOsteoporosisI have none of these.
Type of Cancer:*
Type of Autoimmune Disease:*
Type of STD:*
Type of Skin Disease:*
Blood Transfusion:*

YesNo
Date and Reason for Blood Transfusion:*
Other health conditions not listed above:
Surgical History:
Current Medications:
Social History
Tobacco Use:*

YesNoFormer (no longer use)
Types of tobacco used:*

CigarettesPipeCigarChewE-cigarettes, vape or juul
I last used tobacco on:*
MM/YYYY
Amount used per day:*
Number of years using tobacco:*
Alcohol Use:*

YesNoFormer (no longer use)
Preferred drink:*

WineBeerHard liquor/spiritsOther
I last consumed alcohol on:*
MM/YYYY
Number of drinks per week:*
Recreational Drug Use:*

YesNoFormer (no longer use)
Type used:*

Marijuana / PotCocaineHeroineInhalantsHallucinogensOther
I last used drugs on:*
MM/YYYY
Amount used per week:*
Caffeine:*

YesNoFormer/quit
# of Caffeinated Drinks Per Day:*
Exercise:*

YesNo
Type of Exercise:*
How often do you exercise?*
Do you have any known drug allergies?:*

YesNo
Are you allergic to latex?*

YesNo
Medication Allergies:*
I share a home with:

I live aloneSpouseChild/ChildrenPetsFriend(s)Other

Please answer these Yes/No questions:*

	Yes	No	I Don't know
Are you regularly exposed to second-hand smoke or other potentially harmful substances at home or work?
Do you routinely need physical assistance with activities of daily living such as cooking, dressing, hygiene?
Do you keep guns in your home?
Does everyone in your home receive all routinely recommended immunizations?
Do you feel it is important to wear a seatbelt?
Do you have working smoke detectors in your home?
Do you have regular problems with lack of food in your home?
Do you have regular problems with transportation?
Do you have regular problems paying for housing?
Are you in an abusive relationship or afraid of physical harm from anyone you know?
Are you at risk of acquiring HIV infection or other sexually transmitted disease?
Do any members of your family have genetically linked health problems?
Are you adopted?
Do you use e-cigarettes, vape or juul?

Are you age 65 or older?*

YesNo

Over the past two weeks, how often have you been bothered by any of the following:*

	Not at All	Several Days	Half the Days	Nearly Every Day
Little interest or pleasure in doing things
Feeling depressed or hopeless

Wellness Screening History*

	Date	Practice/Location	Result	Does Not Apply
Last Wellness/Routine Physical Exam
Last Colon Cancer Screening
Last Mammogram
Last Dexa (Bone Density) Scan
Last Pap Smear
Last PSA
Last Full Body Skin Cancer Exam
Last Hepatitis C Screening
Last Diabetic Eye Exam

Family History

Please complete each row:

	High Blood Pressure	Heart Disease	Stroke	Cancer	Diabetes	Glaucoma	Asthma	Seizures	Bleeding Disorder	Currently Living	Date of Death	Comments
Father
Mother
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Sibling 1
Sibling 2
Other Relative

Check all that apply:*

I am adopted.I would like to attach additional details about my family medical history.None of these apply.
Attach additional Family History information here.

Browse Files

Cancelof
Insurance Provider*
Insurance Member ID - we need this to verify if we are in network with your insurance*
Previous Primary Care Provider (PCP)*
Reason for leaving your prior PCP:*
How did you hear about our practice?*

Friend or family member referralInternet SearchSocial MediaSigns outside your officeOther
Do you have any family members currently seeing a provider at Central Bucks Family Practice?
Please list their names and relationship to you. If none, leave blank.
Is there anything else you would like our office to know?
Terms & Signatures
CONSENT TO USE AND DISCLOSE HEALTH INFORMATION

This consent authorizes Central Bucks Family Practice to use and disclose health information about you for treatment, payment and health care operations.

Explanation of rights – Read this before signing the consent

Central Bucks Family Practice has a Notice of Privacy Practices that describes how we use and disclose protected health information about you and how you can access your protected health information. You may review our current notice prior to signing this consent. We reserve the right to change our Notice of Privacy Practices and to make the terms of any change effective for all protected health information that we maintain. You may obtain a revised notice by submitting a written request to our Privacy Officer.

You have the right to request that we restrict how your protected health information is used or disclosed to carry out treatment, payment or health care operations. We are not required to agree to any requested restrictions. However, if we agree to a requested restriction, we are bound by the restriction.

You have the right to revoke this consent, except to the extent that we have taken action in reliance on the consent. To revoke this consent, you must submit a written revocation to our Privacy Officer.

Current contact information for our Privacy Officer:

Practice Name: Central Bucks Family Practice

Attention: Privacy Officer

Telephone: 215-348-1706

Facsimile: 215-348-0321

Address: 252 West Swamp Road, Suite 41, Doylestown, PA 18901

Consent

I have read and understand the above Explanation of Rights and have been provided the opportunity to review the Notice of Privacy Practices for Central Bucks Family Practice prior to signing this consent. I authorize Central Bucks Family Practice to use and disclose health information to the parties I provided for treatment, payment and health care operations in accordance with its’ Notice of Privacy Practices.

I acknowledge that the information and contacts I provided today is accurate.

I hereby authorize Central Bucks Family Practice to release any information acquired in the course of my examination or treatment for insurance claims, and authorize payment directly to Central Bucks Family Practice of the surgical and/or medical benefits, in any, otherwise payable to me for their services. I understand I am financially responsible for all charges not covered by this authorizations and guarantee payment of this account.
Please retype the name of the person submitting this form:*

First NameLast Name
I am the:*

PatientPatient's Legal GuardianOther
Please use your mouse or finger to sign:*

Clear
By signing you attest that the medical history form information is true, accurate and complete to the best of your knowledge and understand that any falsification, omission, or concealment of material fact may subject you to dismissal from the practice
Today's Date:*
Please use MM/DD/YYYY format.
Should be Empty:

	Yes	No	I Don't know
Have you felt unsteady or fallen more than once in the past year?
Can you switch a light on/off easily from your bed without fear of falling?
Are floors and walkways in your home safe and in good repair?
Is it difficult to get out of bed or off a chair or toilet without assistance?
Is the lighting in your home sufficient for you to see safely?

Welcome!

About You

Contact Information

Communication Preferences

Medical Conditions & History

Social History

Family History

Terms & Signatures