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MEDICAL HISTORY:
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Current Height (feet/ inches)
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Current Weight (lbs)
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Allergies
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No Known Allergies
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Positive for Allergies
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Please list allergy and reaction (ex: Penicillin- rash)
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Surgical History
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No
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Yes
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Please list type of surgery / date of surgery / and reason for surgery
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Medical Hospitalizations
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No
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Yes
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Please list medical hospitalization dates and reason for hospitalization
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Psychiatric Hospitalizations
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No
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Yes
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Please list psychiatric hospitalization dates and reason for hospitalization
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* How many times have you been to an Urgent Care or Emergency Room for a MEDICAL problem within the 6 months?
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* How many times have you been to an Urgent Care or Emergency Room for a PSYCHIATRIC concern within the 6 months?
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Medications
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* Please list any CURRENT Medications, Dose, When and Why you take it (Ex: Prozac 40 mg once a day each morning for anxiety)
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* Please list any CURRENT Supplements/ Vitamins/ Herbs you are taking
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* Please list any significant PAST Medications, Dose, Reason, How long you took it, and Why it was stopped
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Diagnostic History
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Have you been diagnosed with any of the following:
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Cancer
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Please specify condition/ diagnosis
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Cardiovascular Disorder (ex: Hypertension, Heart Attack, Stroke, Arrythmia, CHF, CAD, etc.)
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Please specify condition/ diagnosis
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Degenerative Disorder (ex: Alzheimer's, Parkinson's, ALS, Huntington's, Muscular Dystrophy, etc.)
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Please specify condition/ diagnosis
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Dermatological Disorder (ex: Severe Acne, Shingles, Alopecia, Rosacea, Eczema, etc.)
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Please specify condition/ diagnosis
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Developmental Disorder (ex: Autism, Down Syndrome, Intellectual Disability, Spina Bifida, Cerebral Palsy, etc.)
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Please specify condition/ diagnosis
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Endocrine Disorder (ex: Diabetes, Cushing's, Pancreatitis, Thyroid issues, etc.)
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Please specify condition/ diagnosis
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Hematological- Lymphatic Disorder (ex: Anemia, Sickle Cell, Lymphedema, etc.)
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Please specify condition/ diagnosis
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Immunologic- Rheumatic Disorder (ex:Psoriasis, HIV/ AIDS, Lupus, Scleroderma, Osteoarthritis, Gout, Fibromyalgia, etc.)
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Please specify condition/ diagnosis
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Liver / Kidney Disorder (ex: Hepatitis, Cirrhosis, Renal Failure, Kidney Stones, etc.)
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Please specify condition/ diagnosis
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Mental Health- Psychiatric Disorder (ex: Suicide Attempt, Depression, Anxiety, ADHD, Bipolar, PTSD, Schizophrenia, etc.)
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Please specify condition/ diagnosis
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Musculoskeletal Disorder (ex: Osteoporosis, Carpal Tunnel Syndrome, Tendintitis, etc.)
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Please specify condition/ diagnosis
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Neurologic Disorder (ex: TBI, Spinal Cord Injury, Encephalitis, Multiple Sclerosis, Meningitis, etc.)
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Please specify condition/ diagnosis
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Nutritional Disorder (ex: Anorexia, Binging/ Purging, Obesity, Vitamin Deficiency, etc.)
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Please specify condition/ diagnosis
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Reproductive Disorder (ex: Endometriosis, PCOS, Prostate issues, Sexual Dysfunction, etc.)
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Please specify condition/ diagnosis
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Respiratory Disorder (ex: Asthma, Obstructive Sleep Apnea, COPD, TB, etc.)
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Please specify condition/ diagnosis
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Substance Misuse - Addiction
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Please specify condition/ diagnosis
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Vision/ Hearing Disorder (ex: Blindness, Hearing Loss, Glaucoma, Macular Degeneration,etc.)
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Please specify condition/ diagnosis
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Other Condition(s) Not Listed
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Please specify condition/ diagnosis
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CARE COORDINATION:
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Other Provider Information
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Previous or Current Primary Care Physician Name
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PCP Address
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PCP Phone#
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Last PCP Visit
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* Do you see any other Providers/ Specialists? (ex: Psychiatrist, Therapist, Cardiologist, Neurologist, etc.)
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If yes, please list the other Provider's Name, Specialty, and your Last Visit Date
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* Are you able to obtain previous health records from the above Providers if needed?
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* Do you currently have any type of Advanced Directives such as a Living Will or Durable Power of Attorney?
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Pharmacy Information
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Pharmacy Name
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Address
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City
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State
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Zip Code
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Phone number
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FAMILY HISTORY:
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Biological Mother
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Biological Mother Living
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Biological Mother current age
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Biological Mother Deceased
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Biological Mother's age at time of death
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Please state reason for your Mother's death
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Biological Father
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Biological Father Living
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Biological Father's current age
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Biological Father Deceased
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Biological Father's age at time of death
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Please state reason for your Father's death
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Biological Siblings
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Number of Siblings
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Any siblings deceased?
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If yes, please state reason for your Sibling's death and age at time of death
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Family Diagnostic History
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Have any of your immediate, biological family members been diagnosed with any of the following:
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Cancer
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Maternal Grandparent
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Please specify condition/ diagnosis
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Paternal Grandparent
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Please specify condition/ diagnosis
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Biological Mother
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Please specify condition/ diagnosis
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Biological Father
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Please specify condition/ diagnosis
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Sibling
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Please specify condition/ diagnosis
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Child
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Please specify condition/ diagnosis
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Cardiovascular Disorder (ex: Hypertension, Heart Attack, Stroke, Arrythmia, CHF, CAD, etc.)
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Maternal Grandparent
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Please specify condition/ diagnosis
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Paternal Grandparent
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Please specify condition/ diagnosis
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Biological Mother
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Please specify condition/ diagnosis
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Biological Father
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Please specify condition/ diagnosis
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Sibling
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Please specify condition/ diagnosis
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Child
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Please specify condition/ diagnosis
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Degenerative Disorder (ex: Alzheimer's, Parkinson's, ALS, Huntington's, Muscular Dystrophy, etc.)
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Maternal Grandparent
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Please specify condition/ diagnosis
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Paternal Grandparent
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Please specify condition/ diagnosis
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Biological Mother
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Please specify condition/ diagnosis
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Biological Father
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Please specify condition/ diagnosis
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Sibling
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Please specify condition/ diagnosis
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Child
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Please specify condition/ diagnosis
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Dermatological Disorder (ex: Severe Acne, Shingles, Alopecia, Rosacea, Eczema, etc.)
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Maternal Grandparent
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Please specify condition/ diagnosis
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Paternal Grandparent
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Please specify condition/ diagnosis
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Biological Mother
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Please specify condition/ diagnosis
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Biological Father
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Please specify condition/ diagnosis
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Sibling
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Please specify condition/ diagnosis
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Child
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Please specify condition/ diagnosis
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Developmental Disorder (ex: Autism, Down Syndrome, Intellectual Disability, Spina Bifida, Cerebral Palsy, etc.)
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Maternal Grandparent
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Please specify condition/ diagnosis
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Paternal Grandparent
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Please specify condition/ diagnosis
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Biological Mother
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Please specify condition/ diagnosis
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Biological Father
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Please specify condition/ diagnosis
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Sibling
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Please specify condition/ diagnosis
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Child
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Please specify condition/ diagnosis
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Endocrine Disorder (ex: Diabetes, Cushing's, Pancreatitis, Thyroid issues, etc.)
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Maternal Grandparent
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Please specify condition/ diagnosis
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Paternal Grandparent
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Please specify condition/ diagnosis
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Biological Mother
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Please specify condition/ diagnosis
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Biological Father
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Please specify condition/ diagnosis
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Sibling
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Please specify condition/ diagnosis
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Child
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Please specify condition/ diagnosis
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Hematological- Lymphatic Disorder (ex: Anemia, Sickle Cell, Lymphedema, etc.)
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Maternal Grandparent
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Please specify condition/ diagnosis
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Paternal Grandparent
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Please specify condition/ diagnosis
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Biological Mother
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Please specify condition/ diagnosis
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Biological Father
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Please specify condition/ diagnosis
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Sibling
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Please specify condition/ diagnosis
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Child
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Please specify condition/ diagnosis
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Immunologic- Rheumatic Disorder (ex:Psoriasis, HIV/ AIDS, Lupus, Scleroderma, Osteoarthritis, Gout, Fibromyalgia, etc.)
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Maternal Grandparent
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Please specify condition/ diagnosis
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Paternal Grandparent
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Please specify condition/ diagnosis
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Biological Mother
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Please specify condition/ diagnosis
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Biological Father
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Please specify condition/ diagnosis
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Sibling
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Please specify condition/ diagnosis
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Child
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Please specify condition/ diagnosis
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Gastrointestinal Disorder (ex: IBS, GERD, Crohn Disease, Peptic Ulcers, etc.)
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Maternal Grandparent
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Please specify condition/ diagnosis
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Paternal Grandparent
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Please specify condition/ diagnosis
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Biological Mother
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Please specify condition/ diagnosis
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Biological Father
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Please specify condition/ diagnosis
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Sibling
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Please specify condition/ diagnosis
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Child
|
Please specify condition/ diagnosis
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Liver / Kidney Disorder (ex: Hepatitis, Cirrhosis, Renal Failure, Kidney Stones, etc.)
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|
|
Maternal Grandparent
|
Please specify condition/ diagnosis
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Paternal Grandparent
|
Please specify condition/ diagnosis
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Biological Mother
|
Please specify condition/ diagnosis
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Biological Father
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Please specify condition/ diagnosis
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Sibling
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Please specify condition/ diagnosis
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Child
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Please specify condition/ diagnosis
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Mental Health- Psychiatric Disorder (ex: Suicide Attempt, Depression, Anxiety, ADHD, Bipolar, PTSD, Schizophrenia, etc.)
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|
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Maternal Grandparent
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Please specify condition/ diagnosis
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Paternal Grandparent
|
Please specify condition/ diagnosis
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Biological Mother
|
Please specify condition/ diagnosis
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Biological Father
|
Please specify condition/ diagnosis
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Sibling
|
Please specify condition/ diagnosis
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Child
|
Please specify condition/ diagnosis
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Musculoskeletal Disorder (ex: Osteoporosis, Carpal Tunnel Syndrome, Tendintitis, etc.)
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|
|
Maternal Grandparent
|
Please specify condition/ diagnosis
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|
Paternal Grandparent
|
Please specify condition/ diagnosis
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Biological Mother
|
Please specify condition/ diagnosis
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Biological Father
|
Please specify condition/ diagnosis
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Sibling
|
Please specify condition/ diagnosis
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Child
|
Please specify condition/ diagnosis
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Neurologic Disorder (ex: TBI, Spinal Cord Injury, Encephalitis, Multiple Sclerosis, Meningitis, etc.)
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|
|
Maternal Grandparent
|
Please specify condition/ diagnosis
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|
Paternal Grandparent
|
Please specify condition/ diagnosis
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Biological Mother
|
Please specify condition/ diagnosis
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Biological Father
|
Please specify condition/ diagnosis
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Sibling
|
Please specify condition/ diagnosis
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Child
|
Please specify condition/ diagnosis
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Nutritional Disorder (ex: Anorexia, Binging/ Purging, Obesity, Vitamin Deficiency, etc.)
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Maternal Grandparent
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Please specify condition/ diagnosis
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Paternal Grandparent
|
Please specify condition/ diagnosis
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Biological Mother
|
Please specify condition/ diagnosis
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Biological Father
|
Please specify condition/ diagnosis
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Sibling
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Please specify condition/ diagnosis
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Child
|
Please specify condition/ diagnosis
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Reproductive Disorder (ex: Endometriosis, PCOS, Prostate issues, Sexual Dysfunction, etc.)
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Maternal Grandparent
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Please specify condition/ diagnosis
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Paternal Grandparent
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Please specify condition/ diagnosis
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Biological Mother
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Please specify condition/ diagnosis
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Biological Father
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Please specify condition/ diagnosis
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Sibling
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Please specify condition/ diagnosis
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Child
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Please specify condition/ diagnosis
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Respiratory Disorder (ex: Asthma, Obstructive Sleep Apnea, COPD, TB, etc.)
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Maternal Grandparent
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Please specify condition/ diagnosis
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Paternal Grandparent
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Please specify condition/ diagnosis
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Biological Mother
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Please specify condition/ diagnosis
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Biological Father
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Please specify condition/ diagnosis
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Sibling
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Please specify condition/ diagnosis
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Child
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Please specify condition/ diagnosis
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Substance Misuse - Addiction
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Maternal Grandparent
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Please specify condition/ diagnosis
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Paternal Grandparent
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Please specify condition/ diagnosis
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Biological Mother
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Please specify condition/ diagnosis
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Biological Father
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Please specify condition/ diagnosis
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Sibling
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Please specify condition/ diagnosis
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Child
|
Please specify condition/ diagnosis
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Vision/ Hearing Disorder (ex: Blindness, Hearing Loss, Glaucoma, Macular Degeneration,etc.)
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|
Maternal Grandparent
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Please specify condition/ diagnosis
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Paternal Grandparent
|
Please specify condition/ diagnosis
|
|
Biological Mother
|
Please specify condition/ diagnosis
|
|
Biological Father
|
Please specify condition/ diagnosis
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Sibling
|
Please specify condition/ diagnosis
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Child
|
Please specify condition/ diagnosis
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Other Condition(s) Not Listed
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Maternal Grandparent
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Please specify condition/ diagnosis
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Paternal Grandparent
|
Please specify condition/ diagnosis
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Biological Mother
|
Please specify condition/ diagnosis
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Biological Father
|
Please specify condition/ diagnosis
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Sibling
|
Please specify condition/ diagnosis
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Child
|
Please specify condition/ diagnosis
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Unknown Biological Family Medical History
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Thank You for taking the time to finish your Pre-Appointment Check-In !!
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NEXT:
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1. Please take another moment to review all of your answers to ensure correctness and completeness.
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2. Then review and sign the HIPAA consent found below and click on "I'm done."
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3. You will then be re-directed back to the main Onpatient appointment screen.
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4. Remember to log back into your Onpatient portal at the time of your appointment to join your video visit.
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