Adult Health History Record PLEASE TYPE OR CLEARLY PRINT ALL INFORMATION IN BLUE OR BLACK INK. PART I: ADULT RECORD Adult Name Birth Date Sex Address/City/State/Zip Family E-Mail Address (For GSNC use only) Cell Phone Day Time Telephone Evening Phone () () () HEALTH INFORMATION PRIVACY STATEMENT.
ADULT HEALTH HISTORY. Adult name. Address. Street City State Zip. Name of family physician. Phone. INSURANCE INFORMATION. Is the participant covered by family medical/hospital insurance? Yes No If so, indicate carrier or plan name. Group # HEALTH HISTORY.
Filling out this form. Answering these questions will help your doctor understand your health and how best to treat you. If you need help filling out this form: Bring this form with you to your appointment and a nurse will help you. OR. Call the clinic at [555-1212 ext. 123] before your appointment and someone can help you over the phone.