New Patient Health History Form

New Patient Health History Form
In order to provide you the best possible care, please complete this form and bring it to your first appointment. All information is strictly CONFIDENTIAL.
Patient Data
First Name
Last Name
Email
example@example.com
*Your email will NOT be shared with any 3rd parties, and is used for occasional office announcements and promotions.
Address

Address

Street Address Line 2

CityCity

Zip
State
Referred by
Telephone (Work)
Format: (000) 000-0000.
(Cell)
Please enter a valid phone number.Format: (000) 000-0000.
(Home)
Please enter a valid phone number.Format: (000) 000-0000.
Age
Date of Birth

MonthDayYear
Date
Social Security
Number of children
Occupation
Employer
Marital Status
Spouse's Name
Spouse's occupation
Spouse's Employer
Spouse's health status
Emergency Contact
Emergency Contact's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Current Complaints
AutomobileWorkOther
Please describe
Date of Injury

MonthDayYear
Date
Date symptoms appeared

MonthDayYear
Date
NoYes
If yes, when?
List of other practitioners seen for this injury/condition
NoYes
If yes, please describe
Insurance Information
Name of party responsible for payment
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name of insurance company
Contact person
YesNo
Claim number
If in an accident, what is your Insurance Company Name
Phone
Format: (000) 000-0000.
Signatures
Name of the insured:
I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Patient’s signature Spouse’s or guardian’s signature
Signature

Clear
Medical History
YesNo
If yes, please describe
YesNo
Date of last physical exam

MonthDayYear
Date
YesNo
If yes, where?
What medications are you taking and for what conditions? (Please list doasge and amounts, etc)
What vitamins, minerals, or herbs do you currently take? Please list for what conditions, dosage, and frequency
Family members - Present and past health conditions (Examples: heart disease, cancer, diabetes, arthritis, etc.)
YesNo
Briefly Explain
NoYes
NoYes
NoYes
NoYes
NoYes
NoYes
NoYes
NoYes
NoYes
NoYes
NoYes
NoYes
What activities aggravate your symptoms?

Habits

Rows	None	Light	Moderate	Heavy
Alcohol
Coffee
Drugs
Exercise
Sleep
Appetite
Soft Drinks
Water
Tobacco
Salty foods
Sugary foods
Artificial sweeteners

AlcoholismAllergiesAnemiaArteriosclerosisArthritisAsthmaBack PainBreast LumpBronchitisBruise EasilyCancerChest Pain/ConditionsCold ExtremitiesConstipationCrampsDepressionDiabetesDigestion ProblemsDizzinessEars RingExcessive MenstruationEye Pain or DifficultiesFatigueFrequent UrinationHeadacheHemorrhoidsHigh Blood PressureHot FlashesIrregular Heart BeatIrregular CycleKidney InfectionKidney StonesLoss of memoryLoss of balanceLoss of smellLoss of tasteLumps In BreastNeck Pain or StiffnessNervousnessNosebleedsPacemakerPolioPoor PostureProstate TroubleSciaticaShortness of breathSinus InfectionSleep problems or InsomniaSpinal CurvaturesStrokeSwelling of anklesSwollen JointsThyroid ConditionTuberculosisUlcersVaricose VeinsVenereal DiseaseOther
Should be Empty:

New Patient Health History Form

Patient Data

Current Complaints

Insurance Information

Signatures

Medical History