Medical History Home»Health History Form Accurate medical history is essential for your care. Help us understand your health better by providing important details. Complete the form below so we can ensure precise treatment during your visit. Please enable JavaScript in your browser to complete this form.Full Name *Address *City *State--- Select Choice ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingZip Code *How Do You Prefer To Be Contacted? *PhoneFaxEmailEmail *Fax NumberPhone Number *Best Time To Call *--- Select Choice ---AnytimeMorning at HomeMorning at WorkAfternoon at HomeAfternoon at WorkEvening at HomeEvening at WorkPreferred DatePreferred TimeCurrent Medical ConditionsDo You Take Any Food/Vitamin Supplements?YesNo I Prefer behalf Do You Smoke?YesNoDo You Exercise?YesNoHow Well Do You Sleep?GoodAverageRestlessPoorAverage Hours Of Sleep Per Night?I consent to the collection, use, storage, and processing of my personal and, where applicable, health-related information, including any data I submit on behalf of others, for the purpose of evaluating or fulfilling my request made through this form. I understand this will be handled in accordance with the Privacy NoticeI consent to the collection, use, storage, and processing of my personal and, where applicable, health-related information, including any data I submit on behalf of others, for the purpose of evaluating or fulfilling my request made through this form. I understand this will be handled in accordance with the Privacy NoticeSubmit