First Health Associates - General Medical History Form

ADVERTISEMENT

FIRST HEALTH ASSOCIATES – General Medical History Form
Name:__________________________________________________________ Date of Birth:_______________ Gender: M F
Primary Care Physician: ____________________________________________________ Phone: ______________________
PCP Address:_____________________________________________________________________________________________
We may send a copy of your treatment plan (as well as all reports, exams and labs) to your primary care
physician. Please, sign here to indicate that you read and understand our policy regarding this. If you have
any questions, please ask.
Patient signature:_______________________________________________________________Date:____________________
Past Medical History
Are you currently being treated by another medical professional for any condition – either new problem or
chronic problem?
No, I only go for checkups
Yes, please see below
Condition
Date of onset
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Have you, in the past, been treated for anything other than routine, short-lived illnesses (colds, flu, etc)?
No, only for checkups and simple problems
Yes, see below
Condition
Date of onset
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Have you ever had surgery?
Yes, please see below
No, never
Condition
Date of surgery (month, year)
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Have you ever seen someone for emotional, behavioral or psychological issues (including couples counseling,
anger counseling, grief counseling, etc.)?
Yes
No
Condition
Date
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Patient Signature:__________________________________________________________________ Date:_________________
1

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go
Page of 3