In order for us to obtain a complete medical history and treat the medical condition that you are seeking help with; we need this form filled out as completely as possible.
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Gender
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Female
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Yes or No
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Authorization of Release of Information
I authorize the following person/people to discuss any necessary appointments, treatments, medications, test results, or anything else related to my medical care and/or appointment scheduling. I authorize the following person/people to bring in my child in for treatment and to discuss any appointments, treatments, medications, test results or anything else related to their medical care and/or appointment scheduling.
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Who would you like us to contact in the case of an emergency?
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Yes or No
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Yes or No
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MEDICAL HISTORY
(Please check appropriate boxes)
Heart Attack
Asthma
Diabetes
Emphysema
Coronary Artery Disease
Thyroid
Cancer
Bleeding Disorder
Kidney Disorder
Stroke
Hepatitis
Glaucoma
Hypertension
Heart Failure
Arthritis
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(Insulin Yes/No)
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No
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Past Surgical History (Enter approximate date for procedure that applies)
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Family History (Please write who among your immediate family has the following)