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(661) 384-8550|[email protected]

(661) 384-8550|[email protected]

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Complete Adult Health Historylpd-admin2019-02-01T15:28:05-07:00

Health History - Long Form

Step 1 of 6 - Patient Info

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  • Your answers to the following questions will help us to understand your medical history and the concerns you’d like to discuss with your doctor. Please fill out as much of this questionnaire as possible. If you cannot answer some of the questions or feel uncomfortable answering them, leave them blank. Thank you for your help.
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  • MEDICAL HISTORY

  • Please list any surgeries or hospital stays you have had and their approximate date/year:
  • Type of Surgery:Date: 
  • Please list all medications, including vitamins, herbal or natural supplements and prescription medications, which you are currently taking. Please note the dosage if possible.
  • Medication NameDosage 
  • Are you currently receiving care from any other doctors, chiropractors, or other health care professionals? If yes, we would like to know whom so that we can coordinate your care:
  • Provider’s nameCondition they are treating you for 
  • Please note dates of your most recent immunizations:
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • If you have had any of the following tests done, please note when the tests was done and what the results were, if known:
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • FAMILY HISTORY

  • Check any of the diseases that run in your family and please note who had it:
  • HEALTH HABITS

  • PERSONAL HISTORY

  • SEXUAL HISTORY

  • WOMEN ONLY

  • OTHER COMMENTS:

  • This field is for validation purposes and should be left unchanged.

Let’s change healthcare together.

[email protected]

Phone: (661) 384-8550

Address: 9900 Stockdale Highway Suite 207,
Bakersfield,  CA 93311

  • This field is for validation purposes and should be left unchanged.
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