acehealthclinic.com - New Patient History Form

New Patient Medical History

Please complete this form prior to your first appointment
Name
Date of Birth

MonthDayYear
Date
Age
Sex
Past Medical History

Condition / Disease

Other Medical Condition (not listed above)
Past Surgical Procedures
List operation and Month/yr
Medication Allergies or Intolerances
List below medications causing an allergic reaction (i.e., rash, swelling) or intolerance (i.e., nausea)
Medications, Vitamins and Herbal Supplements
Social, Educational and Work History
Marital Status
Children?
Boys
Girls
Work Status
Current or Prior Occupation
What type of exercises, if any do you perform, duration & frequency?
In what type of residence do you live (i.e., house, assisted living, nursing home)?
Do you drink alcohol?
No. of drinks per week?
Are you a former smoker?
If so, what year did you quit?
No. of years you smoked?
On average, how much did you smoke per day?
Are you sexually active?
Do you have sex with
Do you have a Medical Power of Attorney?
If Yes who?
POA Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Do you have a living will?
Family Health History

Please list below the health history of your blood (genetic) first degree relatives

Review of Systems
Please review the following symptoms and circle those items that are a problem for you
Disease Prevention and Health Maintenance

Please list below the most recent dates of your vaccines and health screening tests

New Patient Medical History