Update Medical History

Update Medical History

PLEASE PROVIDE AN UPDATED, ACCURATE AND COMPLETE LIST OF ALL YOUR MEDICATIONS/HISTORY FOR EACH AND EVERY OFFICE VISIT.
*I understand that ACU relies on the medication information I provide, and that any medication misinformation can result in hospitalization or death. By typing my name below, I acknowledge that the medication information I am providing is accurate and complete.
*Type your Name here*

First NameMiddle NameLast NameSuffix (Jr, Sr, III, ect)
Patient Birth Date*

MonthDayYear
Patient Phone Number*

Area CodePhone Number
Patient Drug/Medication Allergies & Allergic Reactions
Allergic to Mold/Pollen/Dust?*

YesNoUnknown
Any Drug/Medication Allergies?*

YesNoUnknown
Have you had any Hospitalizations/Surgeries?

NoYes
List Hospitalizations/Surgeries below with description.
Any new medical information?
List Drug/Medication Allergies & Reactions:

Name of Medication / Allergic Reaction0/300
Patient Medications

Be sure to include all medications, over-the-counter, diabetic, dietary supplements and vitamins.

Please List All Medications

Patient Tobacco/Alcohol/Caffeine Usage
Tobacco Usage:*

Yes, I Smoke DailyYes, Sometimes I SmokeNo, I Quit SmokingNo, I Never Smoked
Date I Quit Smoking:*

MonthDayYear
# Cigarettes per day?*
Alcohol Consumption*

I don't drink1-4 drinks/month1-2 drinks/day3-4 drinks/day5+ drinks/day
Caffeine Consumption*

I don't use caffeine1-4 cups/month1-2 cups/day3-4 cups/day5+ cups/day
Today's Date*

MonthDayYear
Signature

Clear
Should be Empty:

Patient Medications