Form 1 (Demographics) – iHealth Clinics

Medications
Do you take any medications?*
List your Medications (Over the counter, Prescriptions and Birth Control)*
Name and Dosage How often do you take it Daily?
Are you missing a few?
- Yes
- No
That's OK. We will check with the pharmacy.

Screening Section
Last Menstral period
MM slash DD slash YYYY
Last Menstral Period
Pregnancy Total (Gravida)
Total # of Pregnancies
Pregnancy Deliveries (Para)
Term, Preterm, Abortions (spontaneous or induced) and Living
Recent Colonoscopy
Recent Colonoscopy
Recent Mammogram
Recent Mammogram
Recent DEXA (Bone Density)
Recent DEXA (Bone Density)
Recent Pap Smear
Recent Pap Smear

Surgical History
Have you had any surgeries?
Please list all prior surgeries and approximate dates performed (use the add button)
Surgery Approximate Date

Social History (check all that apply)
Education Level
Current Living Situation
Other living situation*
Smoking/Tobacco Use*
Smoking History*
Type Amount/day # of years
Alcohol
Alcohol History
Drinks/week
Recreatrional Drug Use
Type of Drug use
Type
Are you Sexually Active
Do you wish to have an STD Screen?*
Chlamydia, Gonorrhea, HIV, Herpes (in select cases)
Are there any personal problems or concerns at work, work or school you would like to discuss?
Comments
Are there any cultural or religious concerns you have related to our delivery of care?
Comments
Are there any financial issues that directly impact your ability to manage your health?
Comments
How often do you get the social and emotional support you need?
Comments

Do you see any other Medical Provider regularly?*
List other medical providers you see on a regular basis
Doctors Name Office Phone Other Contact Information

i.e cardiologist, mental health provider, kidney doctor, dentist etc.
Consent
I authorize Ihealth Clinics to Request my Protected Health Information from other Medical Entities
Specific Information that should be disclosed
- Last 24 months office notes/labs/x-ray
- Last 12 months office notes/labs/x-ray
The purpose of this disclose is
- Primary Care Health Records
The authorization will expire on the following date:
Leave Blank If unsure, or No expiration as long as there is patient-doctor relationship.
Are you the patient or a personal Representative?*
Name of Personal Representative*
First Last

Medications

Name (or Organ: Colon, Prostate, Brain)	Approximate Age of diagnoses

Name and Dosage	How often do you take it Daily?

Admitting Diagnoses	Date

Medical Problem	Duration of aforementioned Medical problem

Surgery	Approximate Date