Urgent Care Patient Medical History Form

Patient Information

• Full Name: _________________ Date of Birth: _________
• Address: _________________ Phone: _________________
• Emergency Contact: _________________ Phone: _________________

Current Visit Information

• Reason for Visit: _________________
• Current Symptoms: _________________
• Symptom Duration: _________________
• Pain Level (0-10): ☐0 ☐1 ☐2 ☐3 ☐4 ☐5 ☐6 ☐7 ☐8 ☐9 ☐10

Medical History

Chronic Conditions (check all that apply)

☐ Diabetes ☐ Hypertension ☐ Heart Disease ☐ Asthma/COPD ☐ Arthritis ☐ Other: _________________

Previous Surgeries

Procedure: _________________ Date: _________ Procedure: _________________ Date: _________

Medications

Current Medications

1. Name: _________________ Dosage: _________________
2. Name: _________________ Dosage: _________________
3. Name: _________________ Dosage: _________________

Allergies

☐ No Known Drug Allergies Medication Allergies: _________________ Other Allergies: _________________

Social History

• Tobacco Use: ☐Never ☐Former ☐Current
• Alcohol Use: ☐Never ☐Occasional ☐Regular
• Occupation: _________________

Family History

Certification

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

Signature: _________________ Date: _________