Healthcare Health History Screen

HEALTH HISTORY SCREEN

This Health History Screen collects medical and social information necessary for the provision of appropriate clinical care. All information provided is confidential and will be used in accordance with applicable privacy laws and clinical policies. The patient or authorized representative must provide accurate information and notify the provider of any changes in health status or medications.

Patient Information

Date of Birth:    Gender:    Preferred Pronouns:

Emergency Contact

Insurance Information

Subscriber Date of Birth:    Subscriber Relationship:

Medical History

Chronic Conditions (check all that apply):

Diabetes Hypertension Heart disease Asthma / COPD Cancer Kidney disease

Review of Systems / Current Symptoms

Please check any symptoms you are currently experiencing:

Fever, weight loss Cough, shortness of breath Chest pain, palpitations Abdominal pain, nausea Urinary symptoms Joint or muscle pain

Neurologic symptoms (dizziness, numbness) Psychiatric symptoms (anxiety, depression) Skin rashes or lesions Endocrine (thyroid, hot/cold intolerance)

Social & Behavioral History

Tobacco use: Never Former Current    If current, packs/day:

Alcohol use: Never Social Daily    Typical amount:

Illicit drug use: Yes No    If yes, describe:

Sexually active: Yes No    Partner gender(s):

Pregnancy/Breastfeeding: Pregnant Not pregnant    Last menstrual period:

Mental Health

History of depression: Yes No    History of anxiety: Yes No

Immunizations & Preventive Care

Date of last influenza vaccine:    COVID-19 vaccine most recent date:

Acknowledgment, Consent, and Authorization

I certify that the information provided on this Health History Screen is true and complete to the best of my knowledge. I understand that omission of relevant medical information may affect the safety and appropriateness of treatment. I authorize the healthcare provider to perform necessary examinations and routine treatment as deemed appropriate by the provider.

I hereby authorize the release of medical information necessary for treatment, payment, or healthcare operations to my insurance company and other providers involved in my care. I understand that such disclosures are limited to the minimum information necessary to accomplish the intended purpose and are subject to applicable privacy protections. This authorization is valid for the period beginning on the date signed and expiring on the Authorization Expiration Date below unless earlier revoked in writing.

I acknowledge receipt of a notice of privacy practices describing how my medical information may be used and disclosed and my rights under the privacy rules. I understand I may revoke this authorization at any time by submitting a written request, except to the extent that action has already been taken in reliance upon this authorization.

If patient is a minor or otherwise unable to consent, the signature must be that of a parent or legally authorized representative. By signing below, the signer certifies authority to act on behalf of the patient if signing in a representative capacity and agrees to provide documentation of such authority upon request.

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