Medical History Form

Completing this form as accurately as possible will enable Dr. Geller to review your health history before meeting with you so you can spend time on the issue at hand. Please note the following is only for those with a confirmed scheduled appointment—do not fill this form out if you do not have an appointment.

Full Name *
Full Name
Birthdate *
Address *
Preferred Contact Number *
Preferred Contact Number
Secondary Contact Number
Secondary Contact Number
List any medicine(s) or food(s)
Please list any conditions you have such as diabetes, hypothyroidism, etc.
Please list any surgeries and dates.
Family History
List any medical conditions in your family such as diabetes, heart disease, and cancers.
Personal Information
List any poor habits such as smoking, teeth grinding, etc.
Vegetarian, gluten-free, junk food, etc.
What activities do you do and how often?
Please include any over-the-counter medications you take, dose, and frequency.
Please tell us the name and address of your preferred pharmacy.
Vaccination Dates
Please list the dates for your last vaccines.
Health Maintenance Dates
Current Physicians