SFM Applicant Health History
Patient Form
Date
*
-
Month
-
Day
Year
Date
Applicant Name
*
First Name
Middle Name or Initial
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Applicant Age
*
Current age
Email
*
example@example.com
Phone Number
*
Please the best phone number to reach you.
Format: (000) 000-0000.
Languages Spoken
*
English
Spanish
Hindi
Russian
Other
Language Other
Race
*
Asian
Black/African American
Hawaiian/Pacific Islander
Hispanic/Latin
American Indian/Alaska Native
White
Refuse to Report
Other
Race Other
Ethnicity
*
Hispanic/Latin
Not Hispanic/Latin Race
Unknown
Refuse to Report
Family History (Please mark all that apply):
*
High Blood Pressure
Heart Disease
High Cholesterol
Diabetes
Thyroid Disorder
Asthma
Cancer
Arthritis
Ulcers
Stroke
Seizures
Mental Illness
None of the above
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Medication & Supplements
Integrative Wellness Program
{applicantName}
{dateOf}
{date}
Name
Date of Birth
Date Completed
Enter Current Medications (or upload below). Please press "Save and Add Row" after each entry to save. Leave blank of not currently taking medications.
Current Supplements (or upload below). Please press "Save and Add Row" after each entry to save. Leave blank of not currently taking supplements.
HIPAA Authorization to Transmit PHI by Email
*
I have entered Medication and/or Supplement list(s) above OR will fax Medication and/or Supplement list(s) to Sparks Family Medicine, Ltd at (702) 722-2201.
Upload Medication and/or Supplement list(s). By uploading documents, patient or authorized representative authorizes Sparks Family Medicine and its third-party vendors to transmit uploaded documents as unsecure email attachments. Patients may also fax documents to SFM at (702) 722-2201.
I do not not currently take medications or supplements.
Upload TYPED Current Medication/Supplements List(s)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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Social History
Integrative Wellness Program
{applicantName}
{dateOf}
{date}
Name
Date of Birth
Date Completed
Have you ever regularly smoked or used tobacco products?
*
Yes, in the past but not now.
Yes, now and in the past.
Not now and not in the past.
Please explain smoking/tobacco use (packs per day, years, history, etc.)
*
Have you ever regularly consumed alcohol?
*
Yes, in the past but not now.
Yes, now and in the past.
Not now and not in the past.
Please explain alcohol use (drinks per day, years, history, etc.)
*
Have you ever regularly recreational drugs?
Yes, in the past but not now.
Yes, now and in the past.
Not now and not in the past.
Please explain recreational drug use (drinks per day, years, history, etc.)
*
Have you ever regularly exercised?
Yes, in the past but not now.
Yes, now and in the past.
Not now and not in the past.
Please explain exercise participation, (activities, frequency, history, etc.)
*
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Dental History
Integrative Wellness Program
Do you have or have you had root canals?
*
Yes
No
How many root canals have you had removed?
Have you had wisdom teeth removed?
*
Yes
No
How many wisdom teeth have you had removed?
Do you have or have you had silver (amalgam) fillings?
*
Yes
No
Do you have dental implants?
*
Yes
No
Do you have metal that has been used in dental work, such as gold?
*
Yes
No
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Health Experience and Expectations
Integrative Wellness Program
Please list in chronological order with dates, significant laboratory, imaging results and procedures (please provide copies of relevant results):
*
Please summarize your health history in your own words:
*
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Acknowledgement and Consent
Integrative Wellness Program
{applicantName}
{dateOf}
{date}
Name
Date of Birth
Date Completed
Name of Person Signing this Form
*
First Name
Middle Name or Initial
Last Name
Electronic Signature Acknowledgement and Consent
*
I understand and agree that this electronic signature is the legal equivalent of my signature in writing and I consent to be legally bound to this agreement.
Authorization to Receive Password Protected Attachment
*
I understand I will receive an email response at the provided email from Sparks Family Medicine, Ltd upon submission of this document with a PDF of the completed agreement attachment. I must use the password Applicant#1 to open and save this attachment.
Signature
*
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Submit
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