Medical History and Physical Examination Form
Please provide your medical history and information for your upcoming physical examination. All information is confidential.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Other
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Emergency Contact Name and Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
What is the reason for your visit or current symptoms?
*
Do you have any allergies?
*
No Known Allergies
Medications
Foods
Environmental
Other (please specify)
Please list your current medications (include dosage and frequency)
Have you had any of the following medical conditions?
*
Diabetes
High Blood Pressure
Heart Disease
Asthma
Cancer
Seizures
Other (please specify)
Please provide details of any previous surgeries or hospitalizations (include dates if known)
Family Medical History (check any that apply)
Diabetes
High Blood Pressure
Heart Disease
Cancer
Stroke
Other (please specify)
Lifestyle Information
Rows
Yes
No
Do you smoke?
1
2
Do you consume alcohol?
3
4
Do you exercise regularly?
5
6
Physical Examination Findings (to be completed by healthcare provider)
Signature (Patient or Guardian)
*
Submit
Submit
Should be Empty: