HEALTH HISTORIES FORM

First Name: *

Last Name: *

Date of Birth:

Mobile phone number: *

Email Address *

Pharmacy Name:

Pharmacy Phone Number:

Pharmacy Address/ Intersection:

Please list Allergy and Reaction:

Please list Medication Name, Dose, Frequency, Prescribing Provider and Will we be prescribing moving forward?

Please list additional medications and prescriptions if applicable:

I give Triad Internal Medicine permission to obtain my prescription history through the Medication History Authority so that we may maintain an accurate record of all medications prescribed to you, both within Triad Internal Medicine and other facilities. I am responsible for disclosing all medications I am taking both prescribed and over the counter. I understand that any controlled substances require an agreement and set follow-up visits throughout the year.

I certify that I have read, understand and agreed to the above statement.

VACCINE INFORMATION

Please check if you have got the following vaccines:

Shingrix

Prevnar 13

Pneumovax 65

Tdap (within 10 Years)

Flu Shot

If you have had, please specify when and where:

Date

Patient/ Guardian Signature:

Use your mouse or finger to sign in the box below.