Patient Medical History Form

Patient Health History and Intake Form
Patient Name*

First NameLast Name
Patient Birth Date*

MonthDayYear
Patient's Phone Number*
Please enter a valid phone number.
Patient E-Mail*
example@example.com
Patient's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Gender Assigned at Birth*
Patient Height *
Patient Weight*
Patient's Emergency Contact Person*

First NameLast Name
Patient's Emergency Contact Phone Number*
Please enter a valid phone number.
Reason for Your Visit?*
Patient Medical History
Previous Medical Diagnoses*
Please list any drug or food allergies*
Have you ever had (Please check all that apply)*

AnemiaAsthmaArthritisCancerGoutDiabetesEmotional DisorderEpilepsy SeizuresFainting SpellsGallstonesHeart DiseaseHeart AttackRheumatic FeverHigh Blood PressureDigestive ProblemsUlcerative ColitisUlcer DiseaseHepatitisKidney DiseaseLiver DiseaseSleep ApneaUse a C-PAP machineThyroid ProblemsTuberculosisVenereal DiseaseNeurological DisordersBleeding DisordersLung DiseaseEmphysemaKidney StonesRemoved gallbladderPancreatitis historyHormone ImbalancesMenstrual IssuesAutoimmune DisorderRemoved AppendixRemoved TonsilsInsomniaAnxietyDepressionMood Disorder
Other illnesses not listed above:
Please list any Surgical Operations and Dates of Each*
Please list your Current Medications*
Please list your Current Supplements*
Healthy & Unhealthy Habits
Exercise*

Never1-2 days per week3-4 days per week5+ days per week
Type of exercises you do
Eating following a diet*

I have a loose dietI have a strict dietI don't have a diet plan
What type of diet do you follow, if any?
Alcohol Consumption*

I don't drink1-2 glasses/day3-4 glasses/day5+ glasses/day
Caffeine Consumption*

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day
How stressed is your life currently*

Not at allOnly a littleVery muchI am extremely stressed and it affects my day-to-day life
Do you smoke?*

No0-1 pack/day1-2 packs/day2+ packs/day
Do you vape?*

YesNo
Do you use recreational drugs?*

YesNo
Include other comments regarding your Medical History that I should know
Should be Empty:

Patient Health History and Intake Form

Patient Medical History

Healthy & Unhealthy Habits