General Patient Information and Medical History Form
Today's Date
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-
Month
-
Day
Year
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Date of Birth
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Month
-
Day
Year
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What is your age?
Full Name
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First Name
Last Name
Email Address
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example@example.com
Address
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Street Address
Street Address Line 2
City
State
Zip Code
How were you referred to this office?
What is your gender?
*
Please Select
Male
Female
N/A
Cell Phone Number
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Alternate Phone Number
Emergency Contact Name
Relationship to Contact
Please Select
Spouse
Child
Significant Other
Employee
Employer
Other Adult
Emergency Contact Phone Number
Please enter a valid phone number.
Physicians/Providers/Pharmacy
Primary Care Physician (PCP)
PCP Phone Number
Please enter a valid phone number.
Preferred Pharmacy
*
Pharmacy Phone Number
*
Please enter a valid phone number.
Insurance Information for Labs
Do you have Insurance to use for Labs
*
No, I do not have insurance
Yes, I have Insurance
Primary Insurance Company
*
Policy/Member ID:
*
Group Name and/or Number
*
Insurance Mailing Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Name of Policy Holder
*
Policy Holder's DOB
*
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Month
-
Day
Year
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Relationship to Insured/Policy Holder
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Please Select
Self
Spouse
Child
Significant Other
Employee
Employer
Other Adult
Unknown
Image of Insurance Card (Front)
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Image of Insurance Card (Back)
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Medical History
Hospitalizations, Surgeries, Procedures, Transplants and/or Injuries
Rows
Type
Description
Date (MM/DD/YYYY)
#1
Hospitalization
Surgery
Procedure
Transplant
Injury
#2
Hospitalization
Surgery
Procedure
Transplant
Injury
*3
Hospitalization
Surgery
Procedure
Transplant
Injury
#4
Hospitalization
Surgery
Procedure
Transplant
Injury
Medications and Supplements
*
Rows
Medication/Supplement Name
Reason you take
Date Began (MM/DD/YYYY)
Dose
#1
#2
#3
#4
#5
#6
Allergies and Reactions
*
Rows
Allergy
Reaction
#1
#2
#3
#4
Social Habits and Lifestyle
Tobacco Use:
*
Never
Currently
In the Past
How many cigarettes per day?
*
How many years of tobacco use?
*
Alcohol Use:
*
Never
Currently
In the Past
How many drinks per day?
*
How many drinks per month?
*
Family History
Scroll to see full table
Rows
Age (Current)
Age (Death)
Diabetes
Heart Disease
Cancer (specify)
Stroke
Osteoporosis/
Osteopenia
Mental Illness
Other (specify)
Mother
Father
Sibling
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfater
Medical Conditions
Check the medical conditions that apply to you:
Alcoholism or Substance Abuse
Digestive (Ulcerative Colitis, Crohn's Disease, etc.)
High Cholesterol
Arthritis/Joint Disease
Eating Disorders
AIDS/HIV
Allergies/Sensitivities (Medicines, Skin, Food) (Specify below)
Fatty Liver
LIver Disease
Anxiety
Frequent Infections
Lung Disease (Asthma, COPD)
Autoimmune Conditions
Headaches/Migraines
Osteoporosis/Osteopenia
Blood Clot/Phlebitis
Heart Attack
Psychiatric Disorder
Blood Disorders (Specify below)
Heart Disease
Pulmonary Embolism
Cancer (Specify below)
Heart Failure
Stroke
Cirrhosis
Hemochromatosis
Thyroid Disease (Specify below)
Depression
Hepatitis (Specify below)
Urinary difficulties (Incontinence, infections, etc.)
Diabetes
High Blood Pressure
Other (Specify below)
Specify Medical Condition from above (if necessary)
Women's Health
Postmenopausal
Please Select
Yes
No
Perimenopausal
Please Select
Yes
No
Hysterectomy
Please Select
Total
Partial
No
First Date of Last Menstrual Cycle
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Month
-
Day
Year
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Duration of Menses (days)
Unusual Character of Menses
Please Select
Yes
No
Date of Last Pap Smear
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Month
-
Day
Year
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Past Birth Control Use?
Please Select
Yes
No
Current Birth Control User?
Please Select
Yes
No
Birth Control Type
How long did you use the Birth Control (years)?
Abnormal Pap Smear?
Please Select
Yes
No
Date of Last Mammogram
-
Month
-
Day
Year
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Vaginal Discharge or Sores
Please Select
Yes
No
PCOS
Please Select
Yes
No
Fertility Problems
Please Select
Yes
No
Men's Health
Date of last prostate exam
-
Month
-
Day
Year
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Prostate problems/Cancer
Please Select
Yes
No
Testicular Cancer
Please Select
Yes
No
Date of PSA Test
-
Month
-
Day
Year
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Elevated PSA?
Please Select
Yes
No
Sexual Dysfunction/Impotence
Please Select
Yes
No
Vasectomy
Please Select
Yes
No
Preventative Health
Bone Density Test
Please Select
Yes
No
Date of Bone Density Test
-
Month
-
Day
Year
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Physical
Please Select
Yes
No
Date of Last Physical
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Month
-
Day
Year
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Colonoscopy
Please Select
Yes
No
Date of Colonoscopy
-
Month
-
Day
Year
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Cologuard
Please Select
Yes
No
Date of Cologuard
-
Month
-
Day
Year
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Sleep and Relaxation
Emotional Stress Scale
Low Stress
1
2
3
4
5
6
7
8
9
High Stress
10
1 is Low Stress, 10 is High Stress
How many hours do you usually sleep per night?
What time do you usually go to bed?
Do you wake up feeling refreshed?
Please Select
Yes
No
Exercise and Nutrition
Do you exercise regulary
Yes
No
Describe your exercise regimen
What are your greatest nutrition concerns?
How many meals do you generally eat per day?
Do you skip meals?
Yes
No
Are you currently on a special diet?
Yes
No
What special diet are you on?
What foods do you avoid?
Do you drink coffee?
Yes
No
How many cups per day?
Do you have regular eating habits?
Yes
No
Do you have a healthy appetite?
Yes
No
Do you eat more when feeling depressed or under stress?
Yes
No
Do you experience sudden drops in energy?
Yes
No
When do you experience drops in energy?
What was your weight one year ago?
What is the most you have ever weighed and when?
How often do you have a bowel movement?
I authorize the release of medical information to:
Rows
Name
Relationship
Phone Number
Email Address
#1
Spouse
Child
Employer
Employee
Parent
Significant Other
Other Adult
#2
Spouse
Child
Employer
Employee
Parent
Significant Other
Other Adult
Signature
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