Health Forms Series 3b


Complete the information in the form.

Patient's Name Patient's Age years
    Telephone #
Payment Method Cash Credit Insurance    
Insurance Company Policy #
When was your last checkup?    
Do you take any medications?YesNo Explain
Do you have allergies to medications?  YesNo Explain
What is your problem today? Are you pregnant?YesNo
Put a check by problems you have had:    
allergies   asthma   cancer   diabetes   headaches  

heart attack   high blood pressuretuberculosis

Did you ever stay in the hospital?  Yes No  If yes, what for?    
surgery   illness   pregnancy   delivery  

other:  explain