Care Cross Medical Center

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PATIENT INTAKE AND HISTORY FORM

Do you use a mail order pharmacy? If so, please be sure we have your pharmacy provider information and a copy of your prescription drug card.
***Should your information change, please report these changes in your address, phone contact numbers, insurance, or emergency contact, information to the front desk upon check in at future visits***

Healthcare Maintenance Screening (please list the most recent date if applicable)

Social History

Diagnostic Studies: (mark only those that apply)

Diagnostic Study Date: mm/dd/yy and who and where study performed
Diagnostic Study Date: mm/dd/yy and who and where study performed
Diagnostic Study Date: mm/dd/yy and who and where study performed
Diagnostic Study Date: mm/dd/yy and who and where study performed
Diagnostic Study Date: mm/dd/yy and who and where study performed
Diagnostic Study Date: mm/dd/yy and who and where study performed
Diagnostic Study Date: mm/dd/yy and who and where study performed
Diagnostic Study Date: mm/dd/yy and who and where study performed
Diagnostic Study Date: mm/dd/yy and who and where study performed

ALLERGIES (List name and reaction)

MEDICATION LIST (Please bring all medications with you to your appointment) (Please include all prescription & non-prescription, medications, vitamins and herbal supplements)

Hospitalization/Surgeries Reason/Type of Surgery Date

MEDICAL HISTORY Please check all that apply

FAMILY HISTORY

Mother Father Sister Brother Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Daughter Son Other

SOCIAL HISTORY

FOR FEMALE PATIENTS ONLY

CARE TEAM AND COMMUNICATIONS

Click or drag a file to this area to upload.
Click or drag a file to this area to upload.