Health History

HEALTH HISTORY NOTICE ACKNOWLEDGEMENT

I understand that A Family Healing Center (AFHC) may need access to my medication history and may work in conjunction with my pharmacy and / or insurance carrier to provide accurate medical treatment. AFHC has permission to contact them as needed for this purpose.

Date of Birth(Required)

Pharmacy of choice:

Primary Care Physician

Primary Care Physician Phone Number

Dentist Name

Dentist Phone Number

Past Medical History such as cancer, diabetes, ear infections, eczema, accidents, injuries, mono infection surgeries, organ removals, etc…(please list dates of occurrences

Family History such as cancer, diabetes, heart disease, stroke, migraines, mental illness, or autoimmune condition (please state who in the family had these conditions)

Habits such as alcohol, coffee, smoking, etc…

Excercise:

WOMEN ONLY: Number of Pregnancies

WOMEN ONLY: Live Births

Date Agreed