Patient History Form

Please complete the form prior to your appointment. Once completed either send to us via the Spruce App or bring to your first appointment.

Tell us about yourself:

Habits:

Nutrition Habits:

Exercise Habits:

Psycho/Social:

Allergies or Adverse Drug Reactions:

Past Medical History:

Surgical History:

Do you have Health Care Surrogate/Health Care Directives?

(If yes, please provide a copy at your first visit)

Immunizations: if YES, give approximate year given

Safety:

Transfusions:

SYMPTOM REVIEW

Please mark any symptoms you are currently experiencing or have experienced in the last month:

Anything else?

PLEASE BE SURE TO COMPLETE THIS QUESTIONNAIRE BEFORE YOUR APPOINTMENT