Patient Health History Form
Disclaimer: The information contained in this form is for the sole use of Spectra Health as is appropriate under the HIPAA Privacy Rule. These questions are asked in order to better serve you as a patient of Spectra Health.
Patient Demographics
Patient's Name
*
First Name
Last Name
Preferred Name
Date of Birth
*
/
Month
/
Day
Year
Date
Phone Number
*
Height
*
Weight
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance
*
Email
example@example.com
Gender
*
Male
Female
Transgender Male (f to m)
Transgender Female (m to f)
Other
Non-binary
Decline to answer
Sexual Orientation
*
Lesbian or Gay
Straight
Bisexual
Something Else
Don't know
Decline to Answer
Preferred Pronoun
he/him/his
she/her/hers
they/them/theirs
ze/zim
patient's name
decline to answer
Past Medical History
Have you ever been hospitalized?
*
Yes
No
If yes, what for
Which of the following conditions are you currently being treated or have been treated for in the past?
*
ADHD
Anemia
Anticoagulant Therapy
Anxiety
Arthritis
Asthma
Atrial Fibrillation
Autism
Cancer
Chronic Pain
Congestive Heart Failure
COPD
Crohn's/ Colitis
Depression
Diabetes
Diverticular Disease
Esophageal Reflux
Fibromyalgia
Gastric Ulcer
Heart disease
Hearing loss
Hepatitis
High Blood Pressure
High Cholesterol
HIV/AIDS
Joint Replacement
Lung Disease
Liver Disease
Menopause
Migraine Headaches
Need for Premedication
Osteoporsis
Pacemaker
Peripheral Vascular Disease
Pregnancy
Radiation Treatment
Renal Disease
Seizure Disorder
Sensory Disorder
Stroke Syndrome
Traumatic Brain Injury
Thyroid Disease
Valvular Heart Disease
Cancer- Type
Diabetes- Last A1C
Hepatitis- Type
Pregnancy- Due Date
Sensory Disorder- Please explain
Please list any past/current treatment or surgeries not listed above
*
Do you have any environmental, food or medication allergies?
*
Yes
No
If yes, please list and describe reaction
List Current medications AND the reason for them
*
Signature
Signed
*
Date
/
Month
/
Day
Year
Date
Name of Child (if applicable)
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