Patient form · About 8 minutes

Medical, medication, and allergy history

Your health history helps your clinician prepare before your first visit. Complete what you can — you can fill in gaps at your appointment.

About you

Full name*

Date of birth*

Telephone

Please give at least a telephone number or an email address so the office can reach you.

Medical conditions

Current medical conditions and approximate year of diagnosis

Mental health conditions you have been diagnosed with or treated for

Surgeries and hospitalizations, with years

Significant injuries, including head injuries

Medications and allergies

All current medications with dose and frequency — one per line

Vitamins, supplements, and over-the-counter products

Medication allergies and the reaction each caused

Food, environmental, or latex allergies

Medications that did not work or that you could not tolerate

Behavioral health history

Have you ever received counseling or therapy?*

YesNo

Have you ever been hospitalized for a mental health reason?*

YesNo

Have you ever attempted or seriously considered suicide?*

YesNo

If you answered yes to any of the above, please add context (optional)

Family history

Family history of heart disease, stroke, cancer, diabetes, or thyroid disease

Family history of depression, bipolar disorder, schizophrenia, ADHD, or substance use

Social history

Who lives with you

Work or school situation

Tobacco or nicotine use*

NeverFormerCurrent

Typical alcohol use per week

Other substance use

Days per week of physical activity

Current life stressors you would like your clinician to know about (optional)

Reason for this visit

What would you most like help with?

What would a good outcome look like for you?

Submitting sends your answers directly to K. Johns Medical over an encrypted connection and creates a PDF for your clinician. It does not book an appointment and is not monitored in real time. For an urgent concern, call the office. In an emergency, call 911 or call or text 988.

Medical, medication, and allergy history

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