Health History Health History FILL AND SUBMIT PRINT AND FILL FILL AND SUBMIT Name(Required) DOB(Required) MM slash DD slash YYYY Height(Required) Weight(Required) Primary Care Physician(Required) Pharmacy Name and Address(Required) Purpose of Visit(Required)Past Medical History(Required) None See Below Yes, Past Medical History Add RemoveMedications(Required) None See Below Yes, Medications Add RemoveSurgical History(Required) None See Below Yes, Surgical History Add RemoveAllergies(Required) No Known Drug Allergy See Below Yes, Allergies Add RemoveFamily History: (Prioritize Gastrointestinal Issues)Relationship(Required) Add RemoveCondition(Required) Add RemoveSmoking Status(Required) Never Smoked Current Nicotine (Cigs/Vape) Former Nicotine Current Cannabis Alcohol Status(Required) No/Rare Current Social (0-4 drinks/wk) Current Frequent/Daily (>6 drinks/week) Current Symptoms (Please check all that Apply):Ear, Nose & Throat(Required) Discolored eyes Nosebleeds Loose Teeth Hoarseness Bad Breath None Pulmonary(Required) Asthma Pneumonia Cough Wheeze Shortness of Breath None Cardiology(Required) High Blood Pressure Chest Pain Palpitations Irregular Pulse Low Blood Pressure None Endocrine(Required) Heat/Cold Intolerance Hair Changes Weight Gain Weight Loss Irregular Menses None Neurological(Required) Seizures Change in Vision Headaches Weakness Dizziness None Muscular(Required) Arthritis Neck Pain Back Pain Muscle Pain Joint Pain None Skin(Required) Rashes Redness Warmth Sore Leg Swelling None Neurological(Required) Seizures Change in Vision Headaches Weakness Dizziness None Gastrointestinal & Liver(Required) Difficulty Swallowing Pain with Swallow Food Not Passing Heartburn Belching Nausea Vomiting Loss of Appetite Feeling Full Quickly Bloating Change in Bowels Constipation Diarrhea Black Stool Blood in Stool Jaundice Abdominal Pain Rectal Pain Excessive gas Rectal Leakage None Any Other InfoForm Completed ByName (Print)(Required) Signature(Required)Date(Required) MM slash DD slash YYYY If Patient is Minor, Parent or Caregiver signs the form SignatureDate MM slash DD slash YYYY CAPTCHAUntitledUntitledUntitled Untitled PRINT AND FILL Downlaod Form
