Medical History Questionnaire

Medical History Questionnaire
Client Name*

First NameLast Name
Client SSN
Client Date of Birth*

MonthDayYear
Client ID
Primary Care Provider (PCP) Information
Do you have a Primary Care Provider?*

NoYesOther
If you do not have a Primary Care Provider, we advise you to secure one.
When did you last see your PCP?
Primary Care Physician Name

First NameLast Name
Primary Care Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Care Physician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Other Primary Care Physician's Currently Seeing?

NoYes
Immunizations?

NoYes
Please list immunizations you have received:
Hearing Aids?

NoYes
Date of Last Dental Exam

MonthDayYear
Date
Name of Dentist

First NameLast Name
Dentist Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Ambulation Device?
Medical History
Estimated Last Physical
Date of Last Well Child Exam

MonthDayYear
Date
Medical or Surgical

NoneSurgical TreatmentOther Medical Treatment
Please Explain Treatment
Check all that Apply:*

NoneAnemiaAnemia/bleeding disorderArthritisAutismCancerCerebral PalsyChronic CoughChronic FatigueChronic PainDevelopmental DisabilitiesDiabetesEpilepsy/SeizuresFibromyalgiaGlaucoma/Eye ProblemsHead InjuryHeadachesHeart DiseaseHigh Blood PressureInfectious/Communicable DiseaseKidney/UrinaryLiver DiseaseMale/Female ProblemsNeurological DiseaseNon-AmbulatoryRespiratory/Lung ProblemsSignificant Speech Impairment/Non-VerbalSkin ProblemSoiling/WettingStomach/BowelThyroid/HormoneTumors/CystsWeight Gain or LossOther
Current Medications and Treatments
Are you presently using any non-prescription medicines or herbal remedies on a regular basis?*

NoYes
Please list any non-prescription medicines or herbal remedies here:
Do you currently have any allergies?*

NoYes
Please list allergies and reactions here:
Advanced Directives
Do you have a living will, medical power of attorney, CPR directive, or psychiatric advance directive(WRAP plan)?*

NoYes
Do you wish to receive information regarding advanced directives?

NoYes
Was a copy provided for the electronic health record?

NoYes
By signing your name electronically on this document, you are agreeing that the signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability and admissibility.*

AgreeDisagree
Client/Guardian Signature

Clear
Relationship to Client
Click here if you refuse or are unable to sign:

RefuseUnable
Upload any relevant documents here

Cancelof
Should be Empty:

Medical History Questionnaire

Primary Care Provider (PCP) Information

Medical History

Current Medications and Treatments

Advanced Directives