Patient forms

Medical History Form

Fill this out before your visit and you'll skip the clipboard at check-in. It takes about five minutes, and your signed form goes straight to our office.

Heart of Ohio Wellness Center

Phyllis Sim, FNP-C · Board-Certified Family Nurse Practitioner

108 N. Hartford Street · Centerburg, Ohio 43011 · (740) 507-2612

PATIENT MEDICAL HISTORY

For new patients and for updating your record before each visit. Fields marked * are required.

Patient information

Full legal name (Last, First, MI) *

Date of birth *

Mobile phone *

Email Needed only if you'd like a copy of your form.

Appointment / visit date

Reason for this visit

Preferred pharmacy (name & location)

Nothing has changed since my last visit.Check this if you're an established patient and your conditions, medications, and allergies are the same. You can skip to the signature.

Surgeries & hospitalizations type and approximate year None

Current medications include over-the-counter, vitamins, supplements Not taking any medications

Allergies No known drug allergies

Allergic to (medications, foods, latex)

Reaction

Family history parents, siblings, grandparents — check all that apply

Which family member(s) / other conditions

Social history

Tobacco / nicotine Never Former Current

Alcohol None Occasional Weekly Daily

Women Currently or possibly pregnant Breastfeeding

Certification & electronic signature

Type your full legal name *

Date

Draw your signature with your finger or mouse *

Sign here

Your signature is stored only on the signed PDF sent to our office.

I agree to sign this form electronically and understand my electronic signature is legally binding, the same as a handwritten signature (federal ESIGN Act). * Email me a copy of my signed form.

Your form is sent securely over HTTPS directly to the clinic and is not stored on this website.

Prefer paper? You can still fill out a form when you arrive. Questions: (740) 507-2612 or phyllis@ohioheartwellness.com.