• PATIENT MEDICAL HISTORY OVER 18

    PATIENT MEDICAL HISTORY OVER 18

    (v 1/15/2021)

  • Please complete the following to the best of your ability. If you do not know the answers or feel uncomfortable with the question, please do not answer. 

  • Patient Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Do you have any medication or food allergies?*
  • Do you take any medications (including vitamins) regularly?*

  • Past Medical History

  • Are your immunizations up to date?*
  • Do you have any known medical problems?*
  • Have you ever been hospitalized*
  • Have you had any surgeries?*

  • Family / Social History

  • Do you know your family's medical history?*
  • Are there firearms in your home?*
  • Do you have access the the firearms?
  • Do you see a dentist regularly?*
  • Do you fear for your safety at home?*
  • Today's Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • Thank you for taking the time to anwer the questions.

  • Should be Empty: