Walking Urgent Care Coral Springs, FL Form

Name:

Today's Date

Date Of Birth:

Place Of Birth (State, Country)

Where would you like your prescriptions sent today? Pharmacy name & location:

How did you hear about us (circle): Yellow Pages, Internet, Friend/Family, Other:

Reason For Today’s Visit:

PAST MEDICAL HISTORY

Have you ever been diagnosed with any of the following ?

Cancer: (list type and date diagnosed):

1: Have you ever had a positive TB (tuberculosis), PPD or TINES test?.

Yes No

2: Have you ever had a blood transfusion?

Yes No

3: Have you ever been admitted to the hospital?

Yes No

If yes, for what?

Please list all medications, vitamins, herbal products and/or nutritional supplements you take