If you have already given the information to our patient care coordinator you do not need to fill out this form.
Adult Medical History Form
Your answers on this form will help me understand your medical concerns and conditions. If you are uncomfortable with any question, do not answer it. Best estimates are fine if you cannot remember specific details.You may be called by someone from our office, to obtain a detailed medical history prior to your visit. This is helpful, because it allows me more time to consider and discuss your condition.
Preferred Local Pharmacy
Preferred Mail Order Pharmacy
If you have a mail order form, please bring a copy so we can scan it into our documents
Additional medications can be listed at the end of this form.
If it is easier, you may bring all of your current medications to the office for our review.
Reactions To Medication Foods/Other Agents
Current or Past Medical History
Please list most recent and give best estimate of month and year of administration.