HEALTH HISTORY UPDATE FORM
First Name:
Last Name:
Date of Birth:
Preferred name:
Visit date:
Pronouns:
he/him/his
she/her/hers
they/them/theirs
decline to answer
other
Please describe:
1. Since your last visit, have you developed new medical problems?
Yes
No
2. Since your last visit, were you admitted to the hospital?
Yes
No
3. Since your last visit, have you had any surgery/procedures?
Yes
No
4. Since your last visit, have you developed any new allergies, or had a bad reaction to any medication or food?
Yes
No
5. Since your last visit, have you started any new medications, or changed any medications you were taking?
Yes
No
6. Please describe your tobacco use in the last year:
Smokeless Tobacco (chew/snuff):
Current user
Former user
Never used
Tobacco use:
Current smoker
Former smoker
Never smoked
Type of Use
-- Select --
Cigarettes
Pipe
Cigars
Vape
E-Cigarettes
Amount per day
How long?
When did you quit?
Falls - for patients 65 and above
Have you fallen since your last visit or within the last year? If yes, did the fall result in injury?
Falling includes unintentionally coming to rest on the ground or other level such as a chair.
No
Yes, without injury
Yes, with injury
Please explain:
In the past 12 months, have you been worried or afraid that you might fall?
No
Yes
Please explain:
Influenza Screening
Have you received the flu vaccine since August 1?
No
Yes
Cannot receive due to medical contraindication
FORM COMPLETED BY:
The above information is accurate to the best of my knowledge.
Form completed by:
Date:
Signature: