2 minutes to complete
Any person who has been advised by a doctor, physician, healthcare professional, or any other relevant healthcare provider can fill the Health History Questionnaire.
What is your name?
Date
Please complete the following questions to the best of your ability. If you have any questions, please ask your provider or staff member. The information you provide will be kept confidential.
Please list any medical conditions for which you have been treated:
Please list any medications that you are currently taking (including over-the-counter medications, vitamins, and/or herbs):
Have you ever had any of the following? Select all that apply.