Patient History Form – Simon Family Medicine .

Now Accepting New Patients

775-777-8008

Please call for an appointment.
LIMITED SAME DAY APPOINTMENTS AVAILABLE

OPERATING HOURS

MONDAY to THURSDAY
8:00 am to 5:00 pm

(Closed 1 hour at noon for lunch)

FRIDAY
8:15 am to 12:00 pm

1995 Errecart Blvd., Suite 208
Elko, NV 89801

Conveniently located in the Medical
Plaza, adjacent to the hospital

Now Accepting New Patients

775-777-8008

Please call for an appointment.
SAME DAY APPOINTMENTS AVAILABLE

Patient Health History Form

1995 Errecart Blvd., STE 208, Elko, NV 89801 TEL: 775-777-8008 Fax: 775-996-4318

Consent*
I agree to use electronic records and signatures.
I agree to use electronic records and signatures. I have read and agree to the ELECTRONIC RECORD AND SIGNATURE DISCLOSURE as posted on https://simonfamilymedicine.com/wp-content/uploads/2019/07/Electronic-Record-and-Signature-Disclosure.pdf
Today's Date*
MM slash DD slash YYYY
Patient Name*
First Last
Contact phone number
Date of Birth*
Month
Day
Year
Reason for Visit*

Please be as specific as possible
FAMILY HISTORY
Father
- Living
- Deceased
- heart Disease
- High Blood Pressure
- Stroke
- Cancer
- Glaucoma
- Diabetes
- Epilepsy/Consulsions
- Bleeding Disorder
- Kidney Disease
- Thyroid Disease
- Mental Illness
- Osteoporosis
- Other
What year born?
What age deceased?
What type of cancer?
If Other, please describe
Mother
- Living
- Deceased
- heart Disease
- High Blood Pressure
- Stroke
- Cancer
- Glaucoma
- Diabetes
- Epilepsy/Consulsions
- Bleeding Disorder
- Kidney Disease
- Thyroid Disease
- Mental Illness
- Osteoporosis
- Other
What year born?
What age deceased?
What type of cancer?
If Other, please describe
Father's Father (Paternal Grandfather)
- Living
- Deceased
- heart Disease
- High Blood Pressure
- Stroke
- Cancer
- Glaucoma
- Diabetes
- Epilepsy/Consulsions
- Bleeding Disorder
- Kidney Disease
- Thyroid Disease
- Mental Illness
- Osteoporosis
- Other
What year born?
What age deceased?
What type of cancer?
If Other, please describe
Father's Mother (Paternal Grandmother)
- Living
- Deceased
- heart Disease
- High Blood Pressure
- Stroke
- Cancer
- Glaucoma
- Diabetes
- Epilepsy/Consulsions
- Bleeding Disorder
- Kidney Disease
- Thyroid Disease
- Mental Illness
- Osteoporosis
- Other
What year born?
What age deceased?
What type of cancer?
If Other, please describe
Mother's Father (Maternal Grandfather)
- Living
- Deceased
- heart Disease
- High Blood Pressure
- Stroke
- Cancer
- Glaucoma
- Diabetes
- Epilepsy/Consulsions
- Bleeding Disorder
- Kidney Disease
- Thyroid Disease
- Mental Illness
- Osteoporosis
- Other
What year born?
What age deceased?
What type of cancer?
If Other, please describe
Mother's Mother (Maternal Grandmother)
- Living
- Deceased
- heart Disease
- High Blood Pressure
- Stroke
- Cancer
- Glaucoma
- Diabetes
- Epilepsy/Consulsions
- Bleeding Disorder
- Kidney Disease
- Thyroid Disease
- Mental Illness
- Osteoporosis
- Other
What year born?
What age deceased?
What type of cancer?
If Other, please describe
Brother
- Living
- Deceased
- heart Disease
- High Blood Pressure
- Stroke
- Cancer
- Glaucoma
- Diabetes
- Epilepsy/Consulsions
- Bleeding Disorder
- Kidney Disease
- Thyroid Disease
- Mental Illness
- Osteoporosis
- Other
What year born?
What age deceased?
What type of cancer?
If Other, please describe
Sister
- Living
- Deceased
- heart Disease
- High Blood Pressure
- Stroke
- Cancer
- Glaucoma
- Diabetes
- Epilepsy/Consulsions
- Bleeding Disorder
- Kidney Disease
- Thyroid Disease
- Mental Illness
- Osteoporosis
- Other
What year born?
What age deceased?
What type of cancer?
If Other, please describe
Social History
Status
- Married
- Single
- Divorced
Have you ever used any illegal or street drugs?*
- Never used
- Current user
- Previous user
How long have you been sober?
Occupation
E-Cigarettes (Vape)*
- Never smoked
- Current every day smoker
- Former smoker
Last smoked
MM slash DD slash YYYY
How much do you smoke daily?
Cigarettes*
- Never smoked
- Current every day smoker
- Former smoker
Last smoked
MM slash DD slash YYYY
How many packs a day?
How many years?
Alcohol*
- No History of Alcohol Use
- Beer
- Wine
- Hard Liquor
Beer: How many cans/week?
Wine: How many glass/week?
Hard Liquor: How many glass/week?
Allergies
Any allergies?*
- Yes
- No
Common Allergies
- Ace Inhibitors
- Amoxicillin
- Animal Hair
- Antihistamines
- Aspirin
- Atorvastatin
- Augmentin
- Bee Sting
- Cat Hair
- Cephalosporins
- Dog Hair
- Egg/Poultry
- Environmental Allergy
- Fish Product Derivatives
- Gluten Protein
- Influenza Virus Vaccines
- Lactose
- Latex
- Levodopa
- Macrolides
- Milk Products
- Mumpsvax
- Niacin
- NSAIDS
- Peanut
- Penicillins
- Pollen
- Quinolines
- Salicylates
- Shellfish
- Somatostatin
- Sulfa (Sulfonamides)
- Sulfamethoxazole
- Tetanus Toxoid
- Tetracyclines
- Tricyclic Compounds
- Vitamin C
- Watermelon
- Other
Other Allergy: Please list
Severity
- Mild
- Moderate
- Severe (Anaphylaxis)
Symptoms of allergy

Please describe the symptoms, ie. throat swelling, nausea, wheezing, rash, vomiting, etc)
Symptoms of allergy

Please describe the symptoms, ie. throat swelling, nausea, wheezing, rash, vomiting, etc.
Symptoms of allergy

Please describe the symptoms, ie. throat swelling, nausea, wheezing, rash, vomiting, etc.
Medications
Are you currently taking any medications?*
- Yes
- No
1. Medication
1. Dosage

200 mg, etc.
2. Medication
2. Dosage
3. Medication
3. Dosage
4. Medication
4. Dosage
5. Medication
5. Dosage
6. Medication
6. Dosage
7. Medication
7. Dosage
8. Medication
8. Dosage
9. Medication
9. Dosage
10. Medication
10. Dosage
Are you looking for refills on any controlled medication? (ie Pain Medications, ADD medications)*
- Yes
- No
HOSPITALIZATIONS OR SURGERIES
Have you ever been hospitalized or have had history of surgery?*
- Yes
- No
1 - Reason
1 - Date
2 - Reason
2 - Date
3 - Reason
3 - Date
4 - Reason
4 - Date
5 - Reason
5 - Date
6 - Reason
6 - Date
MEDICAL HISTORY
Check all that apply
- none
- headache
- shortness of breath
- heart palpitations
- heart murmur
- chest pain
- dizziness/fainting
- peripheral vascular disease
- allergies/hay fever
- asthma/emphysema
- bronchitis
- pneumonia
- ulcer
- GI disorder
- lactose intolerance
- gallbladder disease
- prostate disease
- bowel irregularity
- incontinence
- sexual/menstrual dysfunction
- venereal disease
- diabetes
- hepatitis
- anemia
- arthritis
- osteoporosis
- hypertension (high blood pressure)
- depression
- gout
- stroke
- cancer
- rheumatic fever
- glaucoma
- epilepsy/convulsions
- bleeding disorder
- kidney disease
- thyroid disease
- mental illness
- other
If Other, please explain:
E-Signature
Acknowledgement*
- I have read and acknowledge the following statement: Full disclosure of any health issues and current medications is vital to forging and maintaining a good relationship with Simon Family Medicine. Simon Family Medicine maintains the right to dismiss patients who fail to complete this form completely and honestly.
Type your name here to e-sign:*
First Last
Signed Date*
MM slash DD slash YYYY

775-777-8008

775-777-8008

Patient Health History Form

FAMILY HISTORY

Social History

Allergies

Medications

HOSPITALIZATIONS OR SURGERIES

MEDICAL HISTORY

E-Signature