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#3 NEW PATIENT Health History form

Instructions

This health history form is for new patients for their initial visit. This information is securely imported into your chart.

Health History

MM/DD/YYYY
 
 
 
 
check all that apply
 
(Please include any illnesses that were not include in list above)
 
please type none if applicable
 
please describe any serious injuries
 
please list any medications or supplements you are taking with dose and frequency. Please note if you have tried psychiatric medications in the past.
 
Please list any allergies (penicillin, trees, nuts, etc)
 
 
 
 
 
 
 
 
 
 
 
check all that apply
 
 
OK to select more than 1
 
OK to select more than 1
 
 
 
 
 
 
 
 

THANK YOU! Please click "Submit Form" to send to Village Family Clinic.

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