Health History Intake Form - Cascade Internal Medicine Specialists
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4Health History Intake Form
Your physician today:
□ Jeffrey Absalon, MD
□ Sanaz Askari, DO
□ Mark Backus, MD
Today’s Date:______________________________________
Patient Name:______________________________________
Date of Birth:______________________ Age:____________
Previous Primary Care Physician (if any):_________________________________________________
Phone:_____________ Address:_________________________________________________________
Other Physicians involved in your care:___________________________________________________
_____________________________________________________________________________________
Reason for visit today:
__________________________________________________________________________________________
__________________________________________________________________________________________
___________________________________________________________________________
Allergies (Medication/Food, indicate reaction): □ None
__________________________________________
__________________________________________
__________________________________________
Medication List: (Please list name/dose/frequency if known)
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
Family History: (please indicate deceased or alive, medical issues and age)
Father:______________________________________________________________________________
Mother:______________________________________________________________________________
Siblings:______________________________________________________________________________
_____________________________________________________________________________________
Grandparents:__________________________________________________________________________
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