Patient Forms: Adult Health History Form

Your answers to the following questions will help us to understand your medical history and the concerns you’d like to discuss with your doctor. Please fill out as much of this questionnaire as possible. If you cannot answer some of the questions or feel uncomfortable answering them, leave them blank. Thank you for your help.

NOTE: If you are a current patient of Dr. Miller you are not required to fill out this form.

Which location would you like to visit?*

Patient Name:*

Patient Date of Birth:*

Phone*

Email*

Do you have a medical history to report?*

YES, see answers below
NO

Please check to indicate if you have ever had the following conditions:

Other

Please describe the condition

Are you currently taking prescription medications?*

YES, see answers below
NO

Please list all medications, including vitamins, herbal or natural supplements and prescription medications, which you are currently taking. Please note the dosage if possible.

Medication Name	Dosage

Would you like to add a family member?*

YES
NO

Agreement

I consent to having Trailhead Clinics' website store my submitted information so they can respond to my inquiry.

Additional Family Member

Family Member Name

First Last

Family Member Date of Birth

Do you have a medical history to report?

YES, see answers below
NO

Please check to indicate if your family member has ever had the following conditions:

Family Member Other

Please describe the condition

Are you currently taking prescription medications?

YES, see answers below
NO

Please list all medications, including vitamins, herbal or natural supplements and prescription medications, which your family member is currently taking. Please note the dosage if possible.

Medication Name	Dosage

Would you like to add a family member?

YES
NO

Agreement

I consent to having Trailhead Clinics' website store my submitted information so they can respond to my inquiry.

2nd Additional Family Member

Family Member Name

First Last

Family Member Date of Birth

Do you have a medical history to report?

YES, see answers below
NO

Please check to indicate if your family member has ever had the following conditions:

Family Member Other

Please describe the condition

Are you currently taking prescription medications?

YES, see answers below
NO

Please list all medications, including vitamins, herbal or natural supplements and prescription medications, which your family member is currently taking. Please note the dosage if possible.

Medication Name	Dosage

Would you like to add a family member?

YES
NO

Agreement

I consent to having Trailhead Clinics' website store my submitted information so they can respond to my inquiry.

3rd Additional Family Member

Family Member Name

First Last

Family Member Date of Birth

Do you have a medical history to report?

YES, see answers below
NO

Please check to indicate if your family member has ever had the following conditions:

Family Member Other

Please describe the condition

Are you currently taking prescription medications?

YES, see answers below
NO

Please list all medications, including vitamins, herbal or natural supplements and prescription medications, which your family member is currently taking. Please note the dosage if possible.

Medication Name	Dosage

Would you like to add a family member?

YES
NO

Agreement

I consent to having Trailhead Clinics' website store my submitted information so they can respond to my inquiry.

4th Additional Family Member

Family Member Name

First Last

Family Member Date of Birth

Do you have a medical history to report?

YES, see answers below
NO

Please check to indicate if your family member has ever had the following conditions:

Family Member Other

Please describe the condition

Are you currently taking prescription medications?

YES, see answers below
NO

Please list all medications, including vitamins, herbal or natural supplements and prescription medications, which your family member is currently taking. Please note the dosage if possible.

Medication Name	Dosage

Would you like to add a family member?

YES
NO

Agreement

I consent to having Trailhead Clinics' website store my submitted information so they can respond to my inquiry.

5th Additional Family Member

Family Member Name

First Last

Family Member Date of Birth

Do you have a medical history to report?

YES, see answers below
NO

Please check to indicate if your family member has ever had the following conditions:

Family Member Other

Please describe the condition

Are you currently taking prescription medications?

YES, see answers below
NO

Please list all medications, including vitamins, herbal or natural supplements and prescription medications, which your family member is currently taking. Please note the dosage if possible.

Medication Name	Dosage

Would you like to add a family member?

YES
NO

Agreement

I consent to having Trailhead Clinics' website store my submitted information so they can respond to my inquiry.

6th Additional Family Member

Family Member Name

First Last

Family Member Date of Birth

Do you have a medical history to report?

YES, see answers below
NO

Please check to indicate if your family member has ever had the following conditions:

Family Member Other

Please describe the condition

Are you currently taking prescription medications?

YES, see answers below
NO

Please list all medications, including vitamins, herbal or natural supplements and prescription medications, which your family member is currently taking. Please note the dosage if possible.

Medication Name	Dosage

If you need to add additional family members please give us a call at 970-644-5999 after you have submitted your entries.

Agreement

I consent to having Trailhead Clinics' website store my submitted information so they can respond to my inquiry.

Name

This field is for validation purposes and should be left unchanged.

Form: Brief Medication History

Additional Family Member

2nd Additional Family Member

3rd Additional Family Member

4th Additional Family Member

5th Additional Family Member

6th Additional Family Member