Medical History Form

Medical History Form

Provide your medical background for our records.
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
MaleFemale
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.
YesNo
If yes, please list your current medications (name and dosage):
YesNo
If yes, please list your allergies:*
YesNo
If yes, please describe your prior illnesses or surgeries:*
DiabetesHeart DiseaseHigh Blood PressureCancerOther
YesNoFormer smoker
YesNo
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.*

OPT-IN
Should be Empty: