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YOUR HEALTH HISTORY

You can save a lot of time by providing your medical history before the doctor see’s you giving more time for your care.
This is optional and secure but don’t lie. If you are uncomfortable with a question, don’t answer it.

Name

Address

Phone Number

Date of Birth

Parent/Guardian [if patient is a minor or otherwise dependent]

Chief Complaint. Why are you seeking an appointment to see a doctor

List every time you were hospitalized (spent the night in a hospital) since the day you were born and why

List every surgery you've had and every bone you've broken

Have you ever been diagnosed or treated by a doctor for any other significant illness or injury? (list 'em all)

List all ALLERGIES Include medication and food allergies and medications you cannot tolerate

List all medications you take regularly, both prescription and over the counter and any additional medications you've taken in the last 30 days

If you have a prescription for any of the above who writes it?

Regarding Personal Habits please don't disclose anything here that could jeopardize your job, get you in legal trouble, or put you at odds with friends or family. We can discuss these topics during your appointment if they are relevant.

Tobacco?

Cigs Cigars Pipe Chew Vape Daily Occasionally

Alcohol?

Daily Occasionally

Cannabis?

smoke vape edibles daily occasionally

Are you in pain now?

Yes No

How long have you had this pain

Describe it

Do you have any recurring or continuous pain or other symptom that has been on-going?

Yes No

How many years?

Describe it

If you are able, record your temperature, pulse, oxygen saturation, and blood pressure below:

Oxygen Saturation

Temperature

PULSE

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Mobile Urgent Care

Daniel Ziegler, M.D. is an Emergency Medicine Specialist with 30 years of experience in Emergency Medical Care.

Contact us

info@humboldtdoc.com

YOUR HEALTH HISTORY

Mobile Urgent Care

Contact us

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