New Patient
Medical History

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Patient Name

Today's Date

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Date of Birth

Sex

Age

How did you hear about our practice?

Please briefly state in the box below the reason for Your visit

Past Medical History

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Hypertension

Hypertension

Hypertension Year Began

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High Cholesterol

High Cholesterol

High Cholesterol Year Began

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Hypothyroidism (low thyroid)

Hypothyroidism (low thyroid)

Hypothyroidism (low thyroid) Year Began

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COPD, Emphysema or Asthma

COPD, Emphysema or Asthma

COPD, Emphysema or Asthma Year Began

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Diabetes

Diabetes

Diabetes Year Began

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GERD

GERD

Gerd Year Began

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Depression or Anxiety

Depression or Anxiety

Depression or Anxiety Year Began

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Heart Problems

Heart Problems

Heart Problems Year Began

Other Medical History

Past Surgical Procedures / Hospitalizations / Serious Injuries or Fractures

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Operation / Hospitalization / Injury

Month / Yr.

Medication or Food Allergies or Intolerances

List below medications or foods causing an allergic reaction (i.e., rash, swelling) or intolerance (i.e., nausea)

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Medication / Food

Reaction

Medication / Food

Reaction

Medication / Food

Reaction

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Pharmacy Name

Pharmacy Phone #

Location

Medication, Vitamins, & Herbal Supplements

List below all medications, vitamins, & supplements that you are currently taking with the dosage & frequency taken.

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Medication

Example: Tylenol

Strength

500ml

Frequency

1 - twice daily

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Medication/Strength/Frequency

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Patient Name

Checkboxes

I Accept

I, the undersigned, acknowledge and agree that by typing my name, clicking “I Accept,” or by other electronic means, I am signing this document electronically.

Date of Birth

Date

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New Patient Medical History

Past Medical History

Past Surgical Procedures / Hospitalizations / Serious Injuries or Fractures

Medication or Food Allergies or Intolerances

Medication, Vitamins, & Herbal Supplements

New Patient
Medical History