Emory Healthcare Initial History Form

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Patient Label
Initial History Form
Welcome to the Infectious Diseases Clinic of Emory Healthcare. In order for us to get to know you
better and help you with any problem you might have, please fill out this health questionnaire to the
best of your knowledge. If you are not sure, please mark the question with a question mark and we will
discuss it with you at your appointment.
Name: ____________________________
Date: ____|___|_20__
Age: _______ Date of Birth: ____|___|_19__ Height: _____ inch Weight: ______ lbs
Who is your primary provider?
Name: __________________________________________
(Family or primary doctor)
Address: ________________________________________
________________________________________
Who referred you to our clinic?
Name: __________________________________________
(If different from above)
Address: ________________________________________
________________________________________
To whom do you want us to send
Name: __________________________________________
results?
Address: ________________________________________
________________________________________
If we try to reach you, may we leave a message (including information related to your diagnosis?)
on your voice mail/answering machine?
No
Yes, preferred number: (____) ____ - ____ x ______
What is your preferred way to receive lab results? Rank the ways we can contact you in order of
preference.
___Mail
Address: _____________________________________________________________
___Phone
Number: ___________________
This is my ___Home phone ___Work phone ___Cell phone
It is
___OK
___Not OK to leave results on the answering machine
___Email
Address: ______________________________________________________________
It is
___OK
___Not OK
to email actual lab results (There are risks to
confidentiality involved in electronic communications.)
Don’t know
Do you have a Living Will?
No
Yes
Don’t know
Do you have an official Medical Power of Attorney?
No
Yes
If yes, name and phone: _______________________________________________________________
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