Patient History Forms

    First Name

    Middle Initial

    Last Name

    Email Address

    Phone (###-###-####)

    Personal History

    PLEASE CHECK THE BOX IF YOU HAVE BEEN DIAGNOSED WITH THE CONDITION.

    HIGH OR LOW BLOOD PRESURE

    VASCULAR DISEASE

    VLUNG DISEASE

    LUNG DISEASE

    ASTHMA OR COPD

    TB

    BRAIN TUMOR

    MIGRAINE OR HEADACHE

    LOSS OF HEARING

    VISUAL IMPAIRMENTS

    EPILEPSY/SEIZURES

    THYROID DIEASE

    HYPOTHYROID DIEASE

    HYPERTHYROID DIEASE

    GALLBLADDER DISEASE

    GASTRIC ULCER

    GASTRIC REFLUX

    PROSTATE ENLARGEMENT

    BLOOD IN STOOL OR URINE

    ARTHRITIS

    BACK PAIN

    NECK PAIN

    HEPATITIS A, B, C

    LIVER DISEASE

    HIV/AIDS

    KIDNEY DISEASE

    KIDNEY STONES

    DIABETES

    ANXIETY

    DEPRESSION

    MENTAL HEALTH ISSUES

    ADDICTION ISSUES SUCH AS :

    OPIOID DEPENCENCY

    ALCOHOL DEPENDENCY

    SUBSTANCE ABUSE

    ANY OTHER HEALTH ISSUES

    Family History

    I HAVE A FAMILY HISTORY OF:

    HEART DISEASE

    CANCER

    DIABETES

    EPILEPSY/SEIZURE

    LUNG DISEASE

    KIDNEY DISEASE

    DIABETES

    MENTAL DISORDER

    LIVER DISEASE

    ADDICTION

    OTHER CHRONIC CONDITIONS

    Social History

    Please select the box if the answer is 'Yes' to the question.

    Do you live alone?

    Do you have a stable housing situation?

    Do you have children?

    Do you have child custody issues?

    Do you drink alcohol?

    Do you drink caffeinated beverages?

    Do you take non-prescribed drugs?

    Are you employed?

    Are you disabled?

    Do you smoke cigarettes?

    Do you vape?

    Do you have unresolved legal issues?

    Are you on probation?

    Do you have adequate food?

    Do you have transportation?

    Are you under more stress than normal?

    Surgical History

    PLEASE CHECK THE BOX IF YOU HAVE HAD THE SURGERY.

    APPENDECTOMY

    BACK SURGERY

    NECK SURGERY

    CABG

    REMOVAL OF GALLBLADDER

    FOOT SURGERY

    HYSTERECTOMY

    TONSILLECTOMY

    TUBAL LIGATION

    HEART SURGERY

    CARDIAC STENT PLACEMENT

    THYROID SURGERY

    OTHER