Medical History Form
Please provide accurate and detailed information about your medical history. Your health is important to us!
Patient's Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Race
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Ethnicity
*
Please Select
Hispanic or Latino
Not Hispanic or Latino
Other
Gender
*
Male
Female
Other
Contact Information
Email Address
example@example.com
Phone Number
*
Please enter a valid phone number.
Height (inches)
*
Weight (pounds)
*
Vaccine History
Please provide information about your vaccine history.
COVID-19 Vaccine
*
Yes
No
If yes, please provide details (Manufacturer and dates (if known))
Flu Vaccine
*
Yes
No
If yes, please provide details (Date)
RSV Vaccine
Yes
No
Pneumonia Vaccine
Yes
No
Medical History
Check the conditions that apply to you
*
No known medical conditions
Allergies
Alzheimer's/ Dementia
Anemia
Anxiety
Asthma
Arthritis
Barrett's Esophagus
Cancer or History of Cancer
Celiac Disease
Colitis
Crohn's Disease
COPD (emphysema)
Depression
Diabetes (Type 1)
Diabetes (Type 2)
Diverticulitis
Endometriosis
Fatty Liver (NAFLD)
Fibromyalgia
GERD (heartburn)
Gilbert's Syndrome (high bilirubin)
Gout
Grave's Disease or History of Grave's
Heart Disease
Heart Failure
Heart Attack (Myocardial Infarction)
Hepatitis B
Hepatitis C
HIV
Hyperlipidemia (high cholesterol)
Hypertension (high blood pressure)
hypothyroid disease
hyperthyroid disease
Headaches (migraine)
Inflammatory Bowel Disease
Irritable Bowel Disease
Kidney Disease
Liver Failure
Lupus
Multiple Sclerosis
Osteoarthritis
Polycystic Kidney Disease (PKD)
Pulmonary Fibrosis
Psychiatric Conditions
Rheumatoid Arthritis
Sarcoidosis
Scleroderma
Sjogren's
Urinary Tract Infection (recurring)
If YES to Cancer, please list date of diagnosis and type below
Do you have any known allergies?
*
Yes
No
If yes, please list your known allergies
Do you have any current medications?
*
Yes
No
If yes, please list your current medications
Have you had any surgeries or hospitalizations in the past?
*
Yes
No
If yes, please list your surgeries or hospitalizations
Do you smoke?
*
Current
Past
Never
If Current Smoker, please enter what age you were when you started and how much you smoke a day.
If Past Smoker, please enter age when started, and year you quit.
Do you drink Alcohol?
*
Daily
Occasionally
Never
Family Medical History
Do you have any family history of chronic conditions? (Cancer, Diabetes, Heart Disease, etc.)
*
Yes
No
If yes, please list the chronic conditions in your family
Submit
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