Patient Health History
Patient Information
Name
First Name, MI
Last Name
Nickname
What name would you like to be called?
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
Mobile Phone Number
Mobile Phone Carrier
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Age
Social Security Number
Today's Date
-
Month
-
Day
Year
Date
How would you like us to contact you?
Phone
Test Message / SMS
Email
I agree to receive text messages regarding appointments and future studies.
Yes
No
Height in Inches
Weight
Sex
Male
Female
Race
White/Caucasian
Black or African American
American Indian or Alaska Native
Native Hawaiian Other Pacific Islander
Asian / Indian
Ethnicity
Non Hispanic / Latino
Hispanic / Latino
Who referred you to us?
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Next
Emergency Contact Information
Emergency Contact Name
Emergency Phone Number
Emergency Contact Relationship
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Medical History
Have you ever been treated for alcoholism?
Yes
No
If you have been treated for alcoholism, when were you treated?
Have you ever been treated for drug abuse?
Yes
No
If you have been treated for drug abuse, when were you treated?
Have you donated blood within the past 30 / 60 days?
Yes
No
If you have donated blood within the past 30 / 60 days, when did you donate blood?
Have you been diagnosed with COVID-19?
Yes
No
If you have been diagnosed with COVID-19, when were you diganosed?
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Next
Medical History - Habits
Do you consume caffeine: energy drinks, coffee, tablets?
Yes - Currently
Yes - Former
Never
How much caffeine do you consume in a day?
When did you start consuming caffeine?
-
Month
-
Day
Year
Date
When did you stop consuming caffeine?
-
Month
-
Day
Year
Date
Do you consume alcohol?
Yes - Currently
Yes - Former
Never
How much alcohol do you consume in a day?
When did you stop consuming alcohol?
-
Month
-
Day
Year
Date
When did you start consuming alcohol?
-
Month
-
Day
Year
Date
Do you smoke cigarettes?
Yes - Currently
Yes - Former
Never
How many packs of cigarettes do you smoke in a day?
When did you start smoking?
-
Month
-
Day
Year
Date
When did you stop smoking?
-
Month
-
Day
Year
Date
Do you smoke cigars or use chewing tobacco?
Yes - Currently
Yes - Former
Never
When did you start smoking cigars or using chewing tobacco?
-
Month
-
Day
Year
Date
When did you stop smoking cigars or using chewing tobacco?
-
Month
-
Day
Year
Date
Do you do use any of the following? If not, please select "none".
Pipe
Snuff
Vape
None
If you selected pipe/snuff/vape, please indicate if you are a former or current user:
Current
Former
Never
When did you start?
-
Month
-
Day
Year
Date
When did you stop?
-
Month
-
Day
Year
Date
Do you use marijuana in any form: smoking, pills, vaping, etc?
Yes - Current
Yes - Former
Never
When did you start?
-
Month
-
Day
Year
Date
When did you stop?
-
Month
-
Day
Year
Date
Back
Next
Medical History - Allergies
Please indicate if you have any of the following allergies, the date you discovered the allergy, and your reaction.
Aspirin / Tylenol / NSAIDS
Yes
No
When did you discover the allergy?
-
Month
-
Day
Year
Date
What was your reaction?
Codeine / Morphine
Yes
No
When did you discover the allergy?
-
Month
-
Day
Year
Date
What was your reaction?
Sulfa
Yes
No
When did you discover the allergy?
-
Month
-
Day
Year
Date
What was your reaction?
Mycins
Yes
No
When did you discover the allergy?
-
Month
-
Day
Year
Date
What was your reaction?
Penicillin
Yes
No
When did you discover the allergy?
-
Month
-
Day
Year
Date
What was your reaction?
Tetracycline
Yes
No
When did you discover the allergy?
-
Month
-
Day
Year
Date
What was your reaction?
Latex
Yes
No
When did you discover the allergy?
-
Month
-
Day
Year
Date
What was your reaction?
Egg Proteins
Yes
No
When did you discover the allergy?
-
Month
-
Day
Year
Date
What was your reaction?
Adverse reaction to any influenza vaccine?
Yes
No
When did you discover the allergy?
-
Month
-
Day
Year
Date
What was your reaction?
Other / Unlisted: Please specify the allergy
When did you discover the allergy?
-
Month
-
Day
Year
Date
What was your reaction?
Back
Next
Your Health - Skin Conditions
Please review these health conditions / disease, select "yes" or "no" as they relate to your health and provide the dates.
Hives
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Psoriasis
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Eczema
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Sun Spots
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Rosacea
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Acne
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Other / Unlisted (Please specify your condition)
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Back
Next
Your Health - Eye Disorder / Disease
Please review these health conditions/diseases, select "yes" or "no" as they relate to your health and provide the dates.
Cataracts
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Glaucoma
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Dry Eyes
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Macular Degeneration
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Diabetic Retinopathy
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Other / Unlisted (Please specify your condition)
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Back
Next
Your Health - Ear, Nose, & Throat
Please review these health conditions/disease, select "yes" or "no" as they relate to your health and provide the dates.
Seasonal or Environmental Allergies
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Difficulty / Impaired Hearing
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Chronic Sinusitis
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Rhinitis
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Other / Unlisted (Please specify your condition)
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Back
Next
Your Health - Gastrointestinal
Please review these health conditions/disease, select "yes" or "no" as they relate to your health and provide the dates.
Heartburn
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Ulcers
Yes
No
If yes - do you have bleeding ulcers?
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Hernia
Yes
No
If yes - please specify the type of hernia(s):
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Irritable Bowel Syndrome
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Polyps?
Yes
No
If yes - please specify the polyp location
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Hemorrhoids
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Diverticulosis
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
GERD
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Crohn's Disease
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Inflammatory Bowel Disease
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Chronic Diarrhea
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Chronic Constipation
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Opioid Induced Constipation
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Other / Unlisted (Please specify your condition)
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Back
Next
Your Health - Immunologic
Please review these health conditions/disease, select "yes" or "no" as they relate to your health and provide the dates.
HIV / AIDS
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Cancer
Yes
No
If yes - please specify type.
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Herpes Simplex
Yes
No
If yes - please specify oral or genital herpes simplex.
Oral
Genital
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Malaria
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition begin?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Other / Unlisted (Please specify your condition)
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Back
Next
Your Health - Neurological / Psychological
Please review these health conditions/disease, select "yes" or "no" as they relate to your health and provide the dates.
Anxiety or Panic Attacks
Yes
No
If yes - please specify if you have been diagnosed with anxiety or panic attacks.
Anxiety
Panic Attacks
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Depression
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Insomnia
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Major Psychiatric Disorder
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Migraine Headaches
Yes
No
If yes - please specify if with vision disturbances / aura
Yes
No
When did this condition begin?
-
Month
-
Day