Arbor Patient Medical History

PATIENT MEDICAL HISTORY

(v 1/15/2021)
Please complete one medical history for each patient. If you do not know the answers or feel uncomfortable with the question, please do not answer.
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Patient Date of Birth
Who is completing this form?*
Your relationship to the patient*

ParentGuardianSelfOther
Does the patient have any medication or food allergies?*

YesNo
Medication or Food Allergies
Does the patient take any medications (including vitamins) regularly?*

YesNo
Current Medications

Birth History
Do you know the patient's birth history?*

YesNo, patient is adopted and the birth history is unknownNo, patient is not adopted but the birth history is unknown
Where was the patient born?*
List medical problems during pregnancy
Any problems with the baby after birth?