To submit this form, please complete all sections accurately. You may submit via email to the designated healthcare provider’s office or deliver it in person during your visit. For fax submissions, please use the office's fax number provided in your appointment confirmation email.

There are no specific important dates associated with this form, but it is recommended to complete it before your first appointment. Regular updates to your health information are advisable to ensure accurate medical care.

The purpose of this form is to gather comprehensive health information from patients to aid healthcare providers in delivering personalized care. It serves as a critical tool for assessing medical history, current medications, and allergies, which are essential for diagnosis and treatment. By filling out this form, patients contribute to a thorough understanding of their health that informs the medical decisions made by their caregivers.

• 1. Last Name: Space to write the patient's last name.
• 2. First Name: Space to write the patient's first name.
• 3. DOB: Field for entering date of birth.
• 4. Marital Status: Options to select marital status such as single or married.
• 5. Occupation: Space for patient’s current job or occupation.
• 6. Personal Health History: Checkbox selections for various past medical conditions.
• 7. Medications: Input area for listing both prescribed and over-the-counter medications.
• 8. Allergies: Section to document any known allergies to medications or substances.
• 9. Family Health History: Fields to note health conditions among family members.

If the questionnaire is not submitted, it can lead to delays in your healthcare process. Vital health information will not be recorded, potentially affecting the quality of care you receive. Healthcare providers rely on this information for accurate diagnoses and treatment plans.

• Incomplete Health Records: Missing or inaccurate information can hinder proper medical diagnosis.
• Delayed Appointments: Failure to submit may result in postponement of your initial appointment.
• Suboptimal Care: Without necessary information, providers may be unable to create a tailored treatment plan.

• 1. New Patient Registration: Use this form when registering as a new patient to provide essential health information.
• 2. Annual Health Updates: Patients should update this form annually or when there are changes in health status.
• 3. Pre-Appointment Requirements: Complete this prior to an appointment for comprehensive initial assessments.