Health History
Forms
Health History
FILL AND SUBMIT
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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
Remove
Medications
(Required)
None
See Below
Yes, Medications
Add
Remove
Surgical History
(Required)
None
See Below
Yes, Surgical History
Add
Remove
Allergies
(Required)
No Known Drug Allergy
See Below
Yes, Allergies
Add
Remove
Family History: (Prioritize Gastrointestinal Issues)
Relationship
(Required)
Add
Remove
Condition
(Required)
Add
Remove
Smoking 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 Info
Form Completed By
Name (Print)
(Required)
Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
If Patient is Minor, Parent or Caregiver signs the form
Signature
Date
MM slash DD slash YYYY
CAPTCHA
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