03 SFM Platform Applicant Health History

{applicantName}	{dateOf}	{date}
Name	Date of Birth	Date Completed

Enter Current Medications (or upload below). Please press "Save and Add Row" after each entry to save. Leave blank of not currently taking medications.
Current Supplements (or upload below). Please press "Save and Add Row" after each entry to save. Leave blank of not currently taking supplements.
HIPAA Authorization to Transmit PHI by Email*

I have entered Medication and/or Supplement list(s) above OR will fax Medication and/or Supplement list(s) to Sparks Family Medicine, Ltd at (702) 722-2201.Upload Medication and/or Supplement list(s). By uploading documents, patient or authorized representative authorizes Sparks Family Medicine and its third-party vendors to transmit uploaded documents as unsecure email attachments. Patients may also fax documents to SFM at (702) 722-2201.I do not not currently take medications or supplements.
Upload TYPED Current Medication/Supplements List(s)

Cancelof

{applicantName}	{dateOf}	{date}
Name	Date of Birth	Date Completed

{applicantName}	{dateOf}	{date}
Name	Date of Birth	Date Completed

Completion of the following questions is required for SFM Functional Medicine Platform consideration. Please do your best to provide the requested information.
List any history of infections, including common colds:*
Briefly list your five major health concerns in order of their importance to you: *
Please summarize in chronological order with dates any emotional or personal factors that may have affected your health, such as emotional traumas, family issues, etc.:*
What are your expected outcomes from care at this practice? *

Acknowledgment and Consent

Applicant 1 Health History
Name of Person Signing this Form*

First NameMiddle Name or InitialLast Name
Electronic Signature Acknowledgement and Consent*

I understand and agree that this electronic signature is the legal equivalent of my signature in writing and I consent to be legally bound to this agreement.
Authorization to Receive Password Protected Attachment*

I understand I will receive an email response at the provided email from Sparks Family Medicine, Ltd upon submission of this document with a PDF of the completed agreement attachment. I must use the password Applicant#1 to open and save this attachment.
I understand that this is the second of four required forms.*

I will be redirected to complete the Applicant 24-Hour Diet Recall and FM Questionnaire after submitting this form.
Signature*

Clear
Should be Empty:

	Very Unwilling	Unwilling	Neutral	Willing	Very Willing
Significantly modify your diet
Take multiple nutritional supplements each day
Keep a record of everything you eat each day
Modify your lifestyle (work demands, sleep habits)
Practice a relaxation technique
Engage in regular exercise
Have multiple lab tests to assess your progress
See a Nutritionist/Dietitian
See an energy worker
See a health coach

Applicant 1 Health History