Medical History Form

Medical History Form

Provide your medical background for our records.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Are you currently taking any medications?
If yes, please list your current medications (name and dosage):
Do you have any allergies?
If yes, please list your allergies:
Have you had any prior illnesses or surgeries?
If yes, please describe your prior illnesses or surgeries:
Family Medical History (Check all that apply)

Other
Do you smoke?
Do you consume alcohol?
Is there anything else about your health history we should know?
I agree to receive communications from True Health Center Miami, Inc. via SMS/text messages, phone calls, and email regarding appointments, healthcare services, treatment programs, prescriptions, billing, and clinic updates. I understand that message and data rates may apply and that I can opt out at any time by replying STOP to text messages or contacting the clinic. My consent to receive communications is voluntary and not required to receive medical care.
Should be Empty: