Patient History Template Page 2

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Today’s Date: _____________Your Appointment Time: _______ a.m. / p.m. Clinic Location: ________________
Patient Name:
Date of Birth:
What is your “Reminder Preference” for
Race
Ethnicity
 American Indian or Alaska Native
 Hispanic or Latino
communication for you?
SELECT BEST ONE BELOW:
 Home Phone: May leave voice mail Text
 Asian
 Not Hispanic or Latino
 Work Phone: May leave voice mail Text
 Black or African American
 Decline to State
 Cell Phone:
May leave voice mail Text
 Native Hawaiian or Other Pacific
 Email:
Islander
 White
Preferred Primary Language
 Decline to State
English Other:
Social History
Tobacco Use History  Never smoked or used tobacco  Former smoker but quit on _______________(approx. date)
 Current Smoker  Started ____________(approx. date) Amount of cigarettes: _____ per day
 Use tobacco in other forms  _____________________ Amount: _________per day
Alcohol Use History: Did you have a drink containing alcohol in the past year?  NO  YES
If Yes:  How often?  monthly or less ____ drinks per month ____ drinks per week ____ drinks per day
How often >6 drinks on one occasion in past year? Never  Less than monthly  Monthly  Weekly Daily
Allergies and Your Allergic Response: or 
No Known Allergies
Rash Nausea/Vomiting Diarrhea Shortness of Breath Anaphylaxis Other:___________
Rash Nausea/Vomiting Diarrhea Shortness of Breath Anaphylaxis Other:___________
Rash Nausea/Vomiting Diarrhea Shortness of Breath Anaphylaxis Other:___________
Current Medications:
Include prescription drugs, Over-the-Counter drugs, vitamins, minerals, herbals, dietary (nutritional) supplements
 None
#
Medication Name
Dose
Frequency
Route
Oral
1
Oral
2
Oral
3
Oral
4
Oral
5
Oral
6
Oral
7
Oral
8
Patient Signature: ____________________________________________________ Date: ______________________
O F F I C E U S E O N L Y
Blood Pressure: ________ / ________ R L
MRN: ________________________
Staff Signature: __________________________________________________ Date: ________________________
Tobacco Cessation <24 months Hypertension >140/90 or pre-hypertension 120/80 to 139/89
Patient Education from Healthwise:
Physician Signature: ______________________________________________ Date:_________________________
Diagnosis Code(s) from Encounter Form: (1) Primary: _______________Others:______________________________
VCA Patient History Form
Page 2 of 2
October 2, 2017

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