Health Forms Series 2a
Complete the information in the form.
Employer
Payment Method
Cash
Credit
Insurance
Insurance Company
Policy #
Do you take any medications?
Yes
No
Explain
Do you have allergies to medications?
Yes
No
Explain
What is your problem today?
Head ache
Cold
Sore Throat
Fever
Flu
Cough
Leg Hurts
Arm Hurts
Foot Hurts
Arm Hurts
Hand Hurts
Finger Hurts
Back ache
Stomach ache
Ear ache
Are you pregnant?
Yes
No
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