Empower Medical/Mental Packet

PATIENT HEALTH HISTORY QUESTIONNAIRE
The following information is very important to your health. Please take time to fully and completely fill out this questionnaire. If there is not room for a complete history, please use additional paper.
Full Name: (First Middle, Last)*
Preferred Name
DOB:*
Email:*
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:*
SSN:*
Race:*
Ethnicity:*
Legal Gender:*
Gender at Birth:*
Language:*
Religion:*
Primary Care Physician (PCP)*
What is the reason you are seeing the surgeon?*
How long have you had this problem?
Please list any specialty physicians you have seen in the past or are currently seeing if it relates to the issue, along with their addresses and phone numbers.
Physician 1:
Specialty 1:
Phone 1:
Address 1:
Physician 2:
Specialty 2:
Phone 2:
Address 2:

Allergies: List allergies and type of known reaction

Medications: List your current medication including vitamins. All medication must be listed below:

Have you taken any weight loss medications? If so, list the name of medications and when you took it.

EMPOWER Medical/Mental Packet