• Health Solutions PLLC

  • Adult Medical History Form

  • The information from this form will help Carla understand your medical concerns and conditions better. Please include as much information as you can. If you are uncomfortable with any question, leave it blank. Best estimates are fine if you cannot remember exact details.

    If you do not have time to complete the entire form in one sitting, you can return to it later.  An email will be sent to the address you list below with a link to return to the form.

    It may take as long as 15 minutes to complete the form.  Please be patient, completing the form before the appointment will allow us more time to discuss your concerns during your appointment.

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  • Gender*
  • If you have multiple concerns, we may not be able to completely address each of them in one visit. But do list all concerns that you have and we can decide together how best to meet your needs.

  • Past Medical History

  • Previous or current health problems

  • FOR WOMEN ONLY

  • Date of the beginning of your last period:
     - -
  • What are you using for contraception?

  • Select Next

  • Preventive Care History

  • It would be helpful to bring your vaccination record to your appointment if you have access to it.

  • FOR WOMEN ONLY:

  • Select Next

  • FOR MEN ONLY

  • Select Next

  • Family History

  • Mother's history
  • My mother is
  • Father's history
  • My Father is

  • Social History and Lifestyle Habits

  • Marital status
  • Recreational Drug Use History
  • Caffeine intake
  • How do you feel about your current weight?
  • Supplements
  • Risk Assessment

  • Sexual History

    These questions relate to your risk for certain health problems and to frequency of preventive screenings.
  • Sexual History Questions

  • If you are finished, select "Yes" below and then click the "Submit" button when it is displayed. If you wish, you can your answers for your own records.... but don't forget to click the submit button after that!

  • Are you finished?*
  • Should be Empty: