Health History Form

New Patient Health History
Email*
example@example.com
Today's Date

MonthDayYear
As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.
Patient's Name*

First NameMiddle InitialLast Name
Home Phone*
Phone number, area code first
Business/Cell Phone
Phone number, area code first
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Occupation*
Indicate Height Feet, Inches and weight lbs.
Date of Birth*

MonthDayYear
Gender*

MaleFemale
SSN or Patient ID
Emergency Contact
Name*

First NameLast Name
Phone Number*
Phone number, area code first
Relationship to You*

FriendParentSiblingSignificant OtherOther
If you are completing this form for another person, what is your relationship to that person?
Your Name, Relationship

Do you have any of the following diseases or problems? *

	Yes	No	Don't Know
Active Tuberculosis
Persistent cough greater than a 3 week duration
Cough that produces blood
Been exposed to anyone with tuberculosis

Please note:

If you are completing this form in the office and have answered yes to any of the four questions above, please stop and return this form to the receptionist.

Medical Information Continued

Joint Replacement
Have you had orthopedic total joint (hip, knee, elbow, finger) replacement?*

YesNo
If yes, please list the date and any complications
Are you taking or scheduled to begin taking an antiresorptive agent (like Fosamax®, Actonel®, Atelvia, Boniva®, Reclast, Prolia) for osteoporosis or Paget’s disease?...*

YesNo
Since 2001, were you treated or are you presently scheduled to begin treatment with an antiresorptive agent (like Aredia®, Zometa®, XGEVA) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma or metastatic cancer?*

YesNo
If yes, date treatment began

MonthDayYear

New Patient Health History