Adult Health Assessment Form
We strive t o keep our medical records regarding your health history
accurat e and up to date. To ass ist us in this effort we ask that you print out
and complete the following questionnaire befo re your upcoming vis it. This
is particularly important if you a re new to the practice or returning for an
annual physic al or pre-operat ive evalu ation.
We recognize t hat you may have pre vious ly provided us with s ome of t his
information. We appreciate your cooperatio n in bein g as thorough as
possible so that we may include any details that might have been missed in
Please bring the completed form wit h you on the day of your appointment
and give it t o t he nurse or medical assist ant who escorts you to the
examinati on roo m.