Health History Form

Mark the correct box for each symptom listed below:

Mark the correct box for each symptom listed below:

Mark the correct box for each symptom listed below:

WOMEN ONLY: Are you pregnant
Due Date:
Are you taking any medications (prescriptions and/or over-the-counter)? If so, what are you taking?
I hereby auhtorize Your Favorite Nurse Practitioner to examine and treat my condition as deemed appropriate through the use of telehealth visit, and give authority & full consent to treatment plan. It is understood and agreed the amount paid to YFNP upon visit. The patient also agrees that he/she is responsible for all bills incurred at this office. The NP will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis. I acknowledge this state to be true with my signature.
Signature

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MonthDayYear
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number

Area CodePhone Number
If you require medication refills please upload photos of your current medications

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MEDICAL HISTORY