Comprehensive Concierge Medicine Patient History Form

Patient Information

• Full Name: _________________ Date: _________________
• Date of Birth: ______________ Age: __________________
• Preferred Contact Method: □ Phone □ Email □ Text

Current Health Status

Primary Health Concerns

Current Medications

Medical History

Chronic Conditions

□ Hypertension □ Diabetes □ Heart Disease □ Cancer □ Autoimmune Disease □ Other: _______________________

Previous Surgeries/Hospitalizations

Family History

Immediate Family Health Conditions

• Mother: ________________________________________
• Father: ________________________________________
• Siblings: ______________________________________

Lifestyle Assessment

• Exercise Frequency: ______ times per week
• Diet Type: □ Regular □ Vegetarian □ Vegan □ Other
• Sleep Quality: □ Poor □ Fair □ Good □ Excellent
• Stress Level (1-10): _____

Preventive Care History

Last Physical Examination

• Date: ________________
• Findings: ____________

Immunizations

□ Flu Shot (Date: _______) □ COVID-19 (Date: _______) □ Other: ________________

Authorization

I certify that the above information is accurate and complete to the best of my knowledge.

Signature: _________________ Date: _________________