SFCHC Health History Form

Health History Form
Please complete each section of the form below, review our patient disclosures and consent declaration, and electronically sign at the bottom of the page before submitting.
Date*

MonthDayYear
Date
Patient Name*

First NameMiddle NameLast Name
Are you completing this form for another person?*

YesNo
If you are completing this form for another person, please include:
Your Name*
Relationship to Patient*

MEDICATIONS
Please answer the following questions.

If you don't know the answer to the question mark DK.
Are you taking or have you recently taken any prescription or over the counter medicine(s)?*

YesNoDK
If so, please list all medications you are taking, including vitamins, natural or herbal preparations and/or diet supplements with dosages:
1
2
3
4
5
Are you taking or scheduled to begin taking medications for bone pain, osteoporosis, Paget's disease, multiple myeloma or metastatic cancer (e.g. Fosamax®, Actonel®, Boniva®, Aredia® or Zometa®?*

YesNoDK
Date treatment began or scheduled to begin:*
Do you use controlled substances (drugs)?*

YesNoDK

ALCOHOL USE
Please answer the following questions.

If you don't know the answer to the question mark DK.
Do you drink alcoholic beverages?*

YesNoDK
If yes, how much alcohol did you drink in the last 24 hours?*
If yes, how much alcohol do you typically drink in a week?*

ACKNOWLEDGEMENT
Do you have any disease, condition or problem not listed above that you think the physician/dentist should know about?*

YesNoDK
Please explain:*
NOTE: Both Physician/Dentist and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my physician/dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my physician/dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in completion of this form.
Date*

MonthDayYear
Date
Patient Signature or Guardian (if minor)*
Name and relationship (if not patient)*
Should be Empty: