02 SFM Applicant Health History

Medication & Supplements

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

Procedure/Vaccine History

Applicant Health History

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

Please enter dates as two digit month, four digit year, (e.g. "02/2019").
For vaccines, enter the four digit year for each vaccine, (e.g. "2010, 2020").
If none, type "None." If unknown, type "Unknown."

Month/Year of last mammogram:
Month/Year of last pap smear:
Month/Year of last rectal exam:
Month/Year of last colonoscopy:
Month/Year of last prostate exam:
Month/Year of last stress test:
Month/Year of last chest x-ray:
Month/Year of last cholesterol labs:
Year(s) of COVID Vaccination(s):
Year(s) of Influenza Vaccination(s):
Year(s) of Pneumonia Vaccination(s):
Year(s) of Tetanus Vaccination(s):
Year(s) of Hepatitis A Vaccination(s):
Year(s) of Hepatitis B Vaccination(s):
Year(s) of Chicken Pox Vaccination(s):
Year(s) of Measles/Mumps/Rubella Vaccination(s):
Other Vaccination(s) and Year(s):

Health Experience and Expectations

Applicant Health History

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

Completion of the following questions are required for SFM Functional Medicine Program consideration. Please do your best to provide the requested information and use additional paper/documentation if necessary.
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.:*
Please provide a narrative of your health history and medical issues in chronological order with dates from birth to the present. Please include current and past accidents, illnesses, surgeries, hospitalizations, injuries, exposure to toxins, family illnesses and any other factors that may have contributed to your current state of health: *

Health Experience and Expectations

Applicant Health History (cont.)

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

Please list in chronological order with dates all of the health care providers you have consulted, their opinions/treatments and all diagnoses given to you in a timeline sequence, including your opinions about the diagnoses: *
Please list in chronological order with dates, significant laboratory, imaging results and procedures (please provide copies of relevant results):*
Please list in chronological order with dates exposure to environmental, industrial or toxic compounds:*

Health Experience and Expectations

Applicant Health History (cont.)

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

List the treatments, medications or supplements that have improved your health:*
List the treatments, medications or supplements that have not improved your health:*
Please summarize your health history in your own words:*
What are your expected outcomes from care at this practice? *
What do you consider a realistic time frame to see changes in your health? *

Rows	Very Unwilling	Unwilling	Neutral	Willing	Very Willing
How confident are you of your ability to organize and follow through on the above health activities?

Acknowledgement and Consent

Applicant Health History

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

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 Questionnaires/Evaluations after submitting this form.
Signature*
Should be Empty:

Rows	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

SFM Applicant Health History

Medication & Supplements

{applicantName}

{dateOf}

{date}

Social History

{applicantName}

{dateOf}

{date}

Procedure/Vaccine History

{applicantName}

{dateOf}

{date}

Health Experience and Expectations

{applicantName}

{dateOf}

{date}

Health Experience and Expectations

{applicantName}

{dateOf}

{date}

Health Experience and Expectations

{applicantName}

{dateOf}

{date}

Readiness Survey

{applicantName}

{dateOf}

{date}

Acknowledgement and Consent

{applicantName}

{dateOf}

{date}