New Patient Health History Form
Personal Information
Thank you for choosing Greenstem Clinic as your healthcare provider. In order to provide you with the best possible care, we require comprehensive information regarding your medical history. Please fill out this new patient health history form to the best of your ability.
Medical History
Understanding your medical history is crucial to delivering personalized and effective healthcare. Please provide details of any past or current medical conditions, surgeries, hospitalizations, and any allergies you may have experienced.
Past Medical Conditions
Include any chronic conditions, such as diabetes, hypertension, asthma, or any other significant medical conditions you have experienced in the past. Be sure to mention the duration, treatments, and any medications you have taken for each condition. This information helps our medical team evaluate your current health status and determine the most appropriate course of treatment for you.
Surgical History
If you have undergone any surgical procedures in the past, please provide details such as the type of surgery, date of surgery, and the name of the healthcare facility where it was performed. This information helps us understand your surgical history and guide decisions about future treatments or interventions.
Hospitalizations
Include any hospitalizations you have experienced in the past. Mention the reasons for hospitalization, duration of the stay, and the healthcare facility where you received treatment. This information enables us to gain insight into your overall health and any potential complications that may arise during your care.
Medication History
List any prescription medications, over-the-counter drugs, or herbal supplements you are currently taking or have taken in the past. Include the name of the medication, dosage, frequency, and the reason for its use. This information is essential to ensure that any prescribed treatments or medications are compatible with your current regimen and avoid potential drug interactions.
Allergies
If you have any known allergies to medications, foods, environmental factors, or any other substances, please provide details. Include the specific allergen, type of reaction experienced, and the severity of your symptoms. This information helps us to prevent potential allergic reactions and tailor treatments specifically to your needs.
Family History
Knowing your family's medical history can provide valuable insights into potential hereditary conditions or predispositions. Please provide details of any significant medical conditions that your immediate family members, such as parents or siblings, have experienced. This includes conditions such as heart disease, cancer, diabetes, and any other health concerns.
Lifestyle and Habits
We value understanding your lifestyle and habits as they directly impact your overall health and well-being. Please provide information about your diet, exercise routine, sleep patterns, stress levels, and any tobacco, alcohol, or substance use. This comprehensive understanding enables us to address any potential risks and develop personalized healthcare plans for you.
Additional Notes
If there are any additional details or concerns that you would like to share with our healthcare team, please use this space to provide any necessary information. Your input is valuable in ensuring that we can provide you with the most effective care tailored to your needs.
Submission
Once you have completed the form, please review your responses to ensure accuracy and completeness. Hit the submit button to securely send your information to our clinic. We respect your privacy and protect all patient data following industry-standard security measures.
Contact Us
If you have any questions or require further assistance, please don't hesitate to contact our friendly staff. We are dedicated to providing exceptional care and look forward to welcoming you to Greenstem Clinic.
