Patient ID#
Changes in Health History Since Last Visit
Name:
DOB:
A. Please list any changes to your health history below. Include date changes were made. If none, please put “None” or “N/A”:
Smoking Status:
Alcohol Intake:
Surgeries:
Injuries
Hospitalizations:
Donated blood in the last 60 days? (other than XMR) If yes, please list when and where:
Donated plasma in the last 7 days? (other than XMR) If yes, please list when and where:
Medication changes? Please provide a list of all current medications to Lab Technician who will ask you during this appointment.
Women Only:
Date of Last Menstruation Period (MM/DD/YYYY):
Are you currently pregnant?
Is there a chance you could be pregnant now?
Were you pregnant in the last 12 months?
Date last pregnancy ended (if applicable)
Are you currently breastfeeding?
B.
By signing below, I certify that all of this information is accurate and answered honestly to the best of my knowledge.
Signature of Patient:
Please fill all the fields with correct values.
