MHUC Patient Registration

MHUC Patient Registration
PATIENT HEALTH HISTORY
Name*

First NameLast Name
Age*
Date of Birth*

MonthDayYear
Date
Reason for today's visit:*
Symptoms:*
Date of last Tetanus shot (if here for injury):

MonthDayYear
Date
Pharmacy/location:
Do you need a Work/School Excuse?*

YesNo
Was this a work related incident or MVA?*

YesNo
Urgent Care Location:*

Please list allergies (medications/food)
No known allergies
Please list current medications (prescribed and OTC)
No prescribed medications

WOMEN ONLY: Date of last menstrual period:

MonthDayYear
Date
Are you pregnant?

YesNo
Breastfeeding?

YesNo

Current Medical Diagnosis
NONE
Surgeries (related to current issue)
NONE
Family Health History (related to current issue)
NONE
Social History (Please select all that apply)

CaffeineTobaccoAlcoholRecreational Drugs
What kind:
How long:
How much:
Should be Empty: