Patient History Form

  • 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.

  • Date of Birth
     / /
  • Date Today
     / /

  • Tell us about yourself:

  • Home situation
  • Do you have Children?
  • Employment

  • Habits:

  • Do you smoke?
  • Do you use other tobacco products?
  • Do you use alcohol?
  • Do you use illicit drugs?

  • Nutrition Habits:

  • Exercise Habits:

  • Psycho/Social:

  • Allergies or Adverse Drug Reactions:

  • Past Medical History:

  • Surgical History:

  • Rows

  • 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

  • Pneumococcal
  • Hepatitis A
  • Hepatitis B
  • Tetanus
  • Shingles
  • HPV Vaccine

  • Safety:

  • Do you use seatbelts?

  • Transfusions:

  • Have you ever received a blood transfusion?

  • 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

  • Should be Empty: