Big Trees MD Patient History for Allergy Program

Big Trees MD Patient History
Full Name:
Nickname:
Physical Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
Mailing Address: (if different from Physical Address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth:

MonthDayYear
Date
E mail:
example@example.com
Phone:
Format: (000) 000-0000.
Please list emergency contact name(s) and their phone number (s):
Insurance Information

This is where you will upload pictures of your insurance cards.
Please upload a picture of the FRONT of your insurance card(s). *

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Please upload a picture of the BACK of your insurance card(s). *

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Please upload a picture of the FRONT of your PHARMACY BENEFIT insurance card(s).

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Please upload a picture of the BACK of your PHARMACY BENEFIT insurance card(s).

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Getting to Know You!
Where did you grow up?
When did you move to the area?
What jobs have you held and what did you do in each job?
What is the most recent job you've had (or what job did you retire from)?
YesNo
Please explain:
What are your hobbies?
Does anything keep you from your hobbies? Please explain.
Right-handedLeft-handedAmbidextrous
FAMILY HISTORY

Please share more about your family's health history so we can learn more about how you may have been impacted.
What is/was your Mom's name?
YesNo
At what age did she pass and what did she pass from?
Please list any known medical diagnoses in your Mom.
What is/was your Dad's name?
YesNo
At what age did he pass and what did he pass from?
Please list any known medical diagnoses in your Dad.

Please list any other first degree relatives you may have: name, relation, how old they are (or were at time of death), their medical diagnoses.

Rows	Name	Relation	Diagnoses	Age now (or at time of death)	Deceased?
1
2
3
4
5
6
7
8

Medical Care History
Who was your last doctor or practitioner?
At what clinic were they located?
What is their phone number?
Format: (000) 000-0000.
When was your last physical?
YesNo
If so, when was the last time and what were you treated for?
What medical concerns have you been diagnosed with in the past?
YesNo
If so, who do you see for eye care?
Do you have any eye diagnoses that you are treated or monitored for regularly?
YesNo
If so, who do you see for dental care?
Do you have any dental diagnoses that you are treated or monitored for regularly?
Please list any specialists or alternative providers you see, where they are located, what medicines do they prescribe, and what do you see them for?
YesNo
If yes, what type, when, and what was the treatment?
YesNo
If yes, when was your last one and where was it done?
YesNo
If yes, when was your last one and where was it done?
YesNo
If so, how much and how often?
YesNo
If so, when and how often?
YesNo
If so, when and how often?
YesNo
If so, when and how often?
YesNo
Please provide details:
YesNo
Please provide details:
YesNo
Please provide details:
YesNo
Please provide details:
YesNo
Please provide details:
YesNo
Please provide details:
YesNo
Please provide details:
YesNo
Please provide details:
YesNo
Do you have any other medical condition, injury or anything else we should be aware of that we have not mentioned?
Covid-19 History
YesNo
If so, when were you diagnosed and were you treated?
If you were diagnosed with Covid-19 previously, do you have any concerns for persistent Covid-19 symptoms?

When did you get your Covid 19 vaccination(s)? Please provide dates and Lot numbers if you have them available.

Rows	Date	Lot
1st Dose
2nd Dose
Most Recent Booster

Please upload a picture of your Covid-19 vaccination card here.

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Surgical History
YesNo
When was it performed, who performed it and what were your results?
YesNo
Please provide details of those surgeries here.
Preventative Vaccines
Please upload any proof of vaccinations you may have (Flu, Pneumonia, etc.)

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Alternatively, please list vaccinations here

Rows	Date	Date	Date	Date
Flu
Pneumonia 13
Pneumonia 23
Shingrix
Tdap (Tetanus, Diphtheria, Pertussis)
Hepatitis B

Medications and Supplements

Please list medications HERE

Rows	Name of Medication	What illness is this Rx for?	Dose (10)	Unit (mg)	How many times a day do you take the medication?	When do you take your medication?	When did you start this medication?
1
2
3
4
5
6

Please submit any further medications here or through the patient portal.
Allergies
YesNo
Please describe what allergies and reactions you have.
What is your preferred Pharmacy?
Health Goals
What health goals would you like to achieve in the next three months?
What health goals would you like to achieve in the next six months?
What health goals would you like to achieve in the next year?
Before your first meeting, is there anything you would like to share?
Thank you for taking the time to be as detailed as possible.

This form helps us greatly in getting you established in the practice!

Now let's get your first appointment scheduled!!!

~The Big Trees MD Team
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Big Trees MD Patient History

Insurance Information

Getting to Know You!

FAMILY HISTORY

Medical Care History

Covid-19 History

Surgical History

Preventative Vaccines

Medications and Supplements

Allergies

Health Goals