Occupational Medicine

Please take a moment to answer the questions below in order
to best use the time spent with your provider.

Patient Information

Your Name

Company Name

What is the reason for today’s visit?

Your Pharmacy

Pharmacy Location

Family Physician

Physician Location

Please list ALL allergies

List all your Medications (including OTC, vitamins, and supplements)

Social History

Do you smoke tobacco?

Yes No

Do you dip tobacco?

Yes No

Do you chew tobacco?

Yes No

Do you drink alcohol?

Yes No

Submit

To the best of my knowledge the information that I have provided on the Health History Questionnaire is true and correct.

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