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Patient Information

Name

Date of Birth / Social Security Number

Has there been any change in your address or telephone numbers?

Yes No

Has there been any change in your insurance information?

Yes No

Medical History

Are you in good health?

Yes No

Height / Weight

Has there been any change in your medical condition since you last visit?

Yes No

Please list any medications you are currently taking

Medication #1

Medication #2

Medication #3

Medication #4

Medication #5

Medication #6

Medication #7

Medication #8

Medication #9

Medication #10

Medication #11

Medication #12

Medication #13

Medication #14

Medication #15

Medication #16

Medication #17

Medication #18

This section is for women only

Is there a possibility of pregnancy?

Yes No

Expected delivery date:

Are you nursing?

Yes No

Are you taking birth control pills?

Yes No

Verification

I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form.

Signature of patient (Parent or Guardian if Minor)

Click to Sign

Date:-------------

I hereby acknowledge that a copy of this office’s Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any
questions I may have regarding this Notice.

Signature of patient (Parent or Guardian if Minor)

Click to Sign

Date:-------------

truForm by PBHS

Main Header

Demographic Information

Patient Information

Medical History

Medical History

Have you had or do you currently have...

Have you had or do you currently have...

Are you now taking:

Please list any medications you are currently taking

Are you allergic or had a reaction to:

This section is for women only

Conclusion

Verification

Click to Sign

Click to Sign

PBHS truForm is best utilized in portrait mode.

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Main Header

Demographic Information

Patient Information

Medical History

Medical History

Have you had or do you currently have...

Have you had or do you currently have...

Are you now taking:

Please list any medications you are currently taking

Are you allergic or had a reaction to:

This section is for women only

Conclusion

Verification

Click to Sign

Click to Sign

PBHS truForm is best utilized in portrait mode.

Please rotate your device to portrait orientation to begin.

You are in Private Browsing mode.

This form requires that you disable private browsing to continue. Please open a new browser window and reload the form.

This form requires that you disable private browsing to continue.
Please open a new browser window and reload the form.