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.
Which location would you like to visit?*
Patient Name:
Patient Date of Birth:
MM slash DD slash YYYY
Today's Date:
MM slash DD slash YYYY
Phone
Email
What would you like to talk to your doctor about today?

MEDICAL HISTORY
Please list any medication allergies or reactions:
Please check to indicate if you have ever had the following conditions:
- Diabetes (250.00)
- High blood pressure (401.9)
- Asthma (493.20)
- Heart attack (411.89)
- Kidney disease (588.8)
- Hepatitis (571.40)
- Thyroid disease (244.9 hypo; 242.9 hyper)
- Stroke (436)
- Depression (311)
- Emphysema (496)
- Seizures (345.10)
- Tuberculosis (011.90)
- Coronary Artery Disease (414.00)
- Congestive Heart Failure (428.00)
- Arrythmia (427.9)
- Sexually transmitted disease
- Eye problems
- Cancer
- Other
If checked, Sexually transmitted disease – type:
If checked, Eye problems – type:
If checked, Cancer – type:
Other, please explain:
Please list any surgeries or hospital stays you have had and their approximate date/year:
Type of surgery / reason for hospitalization / location*
Type of Surgery: Date:
If you have any other medical problems or serious injuries that are not listed above, please describe them here:
When was your last physical?
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
What pharmacy do you use for prescription medications?
Are you currently receiving care from any other doctors, chiropractors, or other health care professionals? If yes, we would like to know whom so that we can coordinate your care:
Provider’s name Condition they are treating you for
Please note dates of your most recent immunizations:
Tetanus
MM slash DD slash YYYY
Influenza
MM slash DD slash YYYY
Pneumonia
MM slash DD slash YYYY
Hepatitis B
MM slash DD slash YYYY
Other
Date
MM slash DD slash YYYY
Other
Date
MM slash DD slash YYYY
If you have had any of the following tests done, please note when the tests was done and what the results were, if known:
Cholesterol
MM slash DD slash YYYY
Result
Pap smear/pelvic
MM slash DD slash YYYY
Result
Mammogram
MM slash DD slash YYYY
Result
Blood in stool
MM slash DD slash YYYY
Result
HIV
MM slash DD slash YYYY
Result
Colonoscopy
MM slash DD slash YYYY
Result
Hepatitis C
MM slash DD slash YYYY
Result

Step 1 of 6 - Patient Info

MEDICAL HISTORY

FAMILY HISTORY

HEALTH HABITS

PERSONAL HISTORY

SEXUAL HISTORY

WOMEN ONLY

OTHER COMMENTS:

Type of Surgery:	Date:

Medication Name	Dosage

Provider’s name	Condition they are treating you for