Step 2 - Fill Out Medical History (Required for Visit)

PATIENT NAME (LAST, FIRST, MI):

PRESCRIPTION MEDICATIONS

PREVIOUS SURGERIES

ALLERGIES TO MEDICATIONS

List all allergies to medications
Please list all allergies to medications
Please describe allergic reaction: ie; hives, rash, itching, swelling, fever

MEDICAL PROBLEMS: Please check if you have/had the following: Select all that apply.

Check any you have or had
Check any you have or had
Check any you have or had
Check
Check any you have or had
Check any you have or had
Check any you have or had

Describe Other Medical Conditions:

FAMILY MEDICAL HISTORY: (Select all that apply)

Family Members
Medical History
Family Members
Family Members
Medical History
Family Members
Family Members
Medical History (copy)
Family Members
Family Members
Medical History (copy) (copy)
Family Members

CONFIRMATION

Medical History Terms & Conditions
1. YOUR AGREEMENT

I understand that honest and complete answers to each question stated above are important to the provision of my medical care, and I have answered them to the best of my ability. I have been informed that if I am uncertain about any questions on the form, I should ask the doctor or member of the medical staff for assistance. This information is true and accurate to my knowledge.
MM/DD/YYYY

CURRENT MEDICAL HISTORY

Please assist us by letting us know the reason your are here to see us today:
Where is the pain or problem?
Example: Does it ache, burn, etc? Pain after Rest or after activity, etc.?
How severe is the pain or problem on a scale of 1-5 with 5 being the most severe?
How long have you had this pain or problem? When did it start?
Does the pain or problem occur at a specific time?
Where were you at the onset of the pain or problem?
What other associated problems have you been having?
What makes the pain or problem worse or better? Have you had previous episodes?