Doctor Appointment Form

This form is designed to gather essential information needed to provide comprehensive and safe care during your appointment. Please complete all sections to the best of your ability.

1. Patient Demographic Information

First Name

Middle Name

Last Name

Date of Birth

Sex Assigned at Birth

Gender Identity

Preferred Pronouns

Primary Language

Marital Status

2. Contact Information

Primary Phone Number

Secondary Phone Number

Email Address

Permanent Address

Street Address Line 1

Street Address Line 2

City/Town

State/Province/Region

Postal/Zip Code

3. Appointment Details

Date of Appointment

Time of Appointment

Reason for Visit

New Symptoms/Concern

Follow-up

Annual Physical/Check-up

Prescription Refill

Other:

Brief Description of Current Symptoms/Concerns

How long have you had these symptoms?

4. Emergency Contact Information

First Name

Middle Name

Last Name

Relationship to Patient

Phone Number

5. Medical History

A. Current Medications and Supplements

Please list all prescription medications, over-the-counter medications, vitamins, and herbal supplements you are currently taking.

	Medication/Supplement Name	Dosage (e.g., 10mg)	Frequency (e.g., Once Daily)
1
2
3
4
5

B. Allergies

Allergy Type	Select	Substance (e.g., Penicillin, Peanuts, Latex)	Reaction (e.g., Rash, Anaphylaxis)
Medication
Food
Environmental
None known

C. Past Medical Conditions

Please check all that apply and provide the approximate year of diagnosis if possible.

	Medical Condition	Select	Approximate Year of Diagnosis
1	High Blood Pressure (Hypertension)
2	High Cholesterol
3	Diabetes (Type 1 or 2)
4	Asthma / COPD
5	Heart Disease / Stroke
6	Cancer
7	Depression / Anxiety
8	Thyroid Disorder
9	Kidney Disease

D. Past Surgeries and Hospitalizations

	Procedure	Reason	Approximate Year
1
2
3
4
5

6. Lifestyle and Social History

Do you currently use tobacco products (cigarettes, vape, chew)?

Yes

Do you consume alcohol?

Yes

Do you use recreational substances?

Yes

Level of Physical Activity

Choice A

Choice B

Sedentary

Moderately Active

Very Active

Occupation

7. Declaration and Signature

I verify that the information provided on this form is accurate to the best of my knowledge.

Patient/Guardian Signature:

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