Patient Health History Short Form

Save time at the doctor's office and fill out your registration and health history information online! Take a few minutes to fill out this confidential form, click the "Save Print Form" at the bottom.


Patient Information


Items marked with asterisk (*) must be completed.
First Name*
Middle Name
Last Name*
I prefer to be called (Nickname)
Address*
Street
City
State/Province
Zip/Postal Code
Country
Home Phone*--
Work Phone--
Cell/Other Phone--
Email Address
Birthdate (MM-DD-YYYY)*--
Gender
Social Security Number (adults only)--
If patient is a minor, give parent's or guardian's name
Whom may we thank for referring you to our office?


Medical History
 

Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential.

Physician
Date of Last Visit--
Address
Street
City
State/Province
Zip/Postal Code
Country
Phone--

Please check any of the following which apply to you, and add any relevant comments.
Do you have a history of any major illness?
Are you taking any medication?
Have you had any major operations?
Have you ever been involved in a serious accident?
Female patients: Are you pregnant?
Are you currently under the care of a physician?

Please check any of the following that you have had or currently have:
Are there any medical conditions we have not discussed that you feel we should be aware of?