Healthcare History Questionnaire

HEALTHCARE HISTORY QUESTIONNAIRE

Please complete this form to the best of your knowledge. The information provided will be used to assist in diagnosis and treatment. All information is confidential and will be released only in accordance with applicable law or with your authorization. Inaccurate or omitted information may affect care decisions.

Patient Information

Patient Name:    Date of Birth:

Insurance Information

Emergency Contact

Medical History

Do you have or have you had any of the following conditions? Check all that apply:

Family History

Lifestyle

Tobacco use: Current Former Never

Alcohol use frequency:    Exercise frequency:

Reproductive / Gender-Specific

Are you pregnant? Yes No    Breastfeeding? Yes No

Last menstrual period (if applicable):

Immunizations & Preventive Care

Date of last influenza (flu) vaccine:

COVID-19 vaccination status: Vaccinated Partially vaccinated Not vaccinated

Current Concerns / Reason for Visit

Authorizations & Acknowledgements

I certify that the information in this Healthcare History Questionnaire is accurate and complete to the best of my knowledge. I understand that withholding information may be detrimental to my care. I authorize the healthcare providers and entities involved in my care to use and disclose my protected health information as necessary for treatment, payment, and healthcare operations, and I acknowledge receipt of the practice's Notice of Privacy Practices where available.

I authorize release of medical information necessary to process insurance claims and to obtain payment for services. This authorization remains in effect until the authorization expiration date provided below, unless earlier revoked in writing to the extent provided by law.

Permission to leave messages regarding appointments, test results, or billing at the phone number listed: Yes No

Permission to communicate via email for appointment reminders and non-sensitive communications: Yes No

I understand I may revoke authorizations in writing except to the extent that action has already been taken in reliance on this authorization.

Patient Certification

By signing below, I acknowledge that I have read and understand the statements above, that I have had an opportunity to ask questions, and that the foregoing information is true and complete to the best of my knowledge. I consent to treatment as deemed necessary by my treating provider in accordance with professional standards.

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