Patient History Form
 Please complete the following form and submit for yourself or the child(ren) you are registering with our practice. It will be necessary to complete this form for each person you are registering. If you have questions about this form, please contact our office.

Please mark "NA" to all questions that do not apply. You will not be able to complete the form until this is done.

Our medical practice complies with all privacy acts and HIPAA.


Full Name:*
E-Mail Address:*


Patient History
Previous Surgeries:* Include month and year, hospital and type of surgery.


Previous Hospitalizations:* Include month and year, hospital and reason for hospitalization.



Previous Illnesses or Health Challenges:
None
mumps/measles
eczema/skin problems
pneumonia
asthma/wheezing
cancer
hepatitis
HIV/AIDS
hemophilia
abnormal bleeding
allergies
frequent ear infections
bronchitis
T.B./lung disease
high blood pressure
heart disease
kidney/bladder problems
prostate problems
high chlolesterol
diabetes
rheumatic fever
congenital heart defects
convulsions/epilepsy
emotional disorders or suicide attempts
alcohol or drug dependency
stroke
other

Please explain any of the above:


Current medications:* Include drug, dose and how often it is taken. Include any vitamins or supplements.


Drug or food allergies:* List and describe reation.


Family History:* List any other family member with a significant medical history and indicate whether paternal, maternal or sibling.