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  • Health History Form

    United Community Health Center

  • Para ver este formulario en español, haga clic en el menú desplegable en la esquina superior derecha.

  • Date of Birth*
     / /
  • Gender at birth*
  • Current Date
     / /
  • Gender Identity
  • Do you have Advanced Directives (Living Will, Medical Power of Attorney)?*
  • If you do not, are you interested in receiving information for Advanced Directives?*
  • Does UCHC have a copy of your Advanced Directives on file?*
  • Would you provide us with a copy of your Advanced Directives if not on file?*
  • Are you currently taking any medications, including non prescription?*
  • Active Medical Problems/Past Medical History. (Check box if you currently have or have a history of)*

  • Obstetrical History/Gynecological History

  • Are you currently pregnant?*
  • Birth Type(s)
  • Are you still having periods?
  • Have you had a Hysterectomy?
  • If you had a Hysterectomy,*
  • History of abnormal paps?

  • Past Surgeries/Major Hospitalizations

  • Have you had any past surgeries or major hospitalizations?*

  • Family History

    Please list if mother, father, siblings, children or grandparents had this. Please list who and age when diagnosed.

  • Social History

  • Marital Status*
  • Partner/Spouse Date of Birth*
     / /
  • Tobacco Use*
  • Current Alcohol Use*
  • History of alcohol abuse?*
  • Current drug use?*
  • Today's Date*
     / /
  • Reload
  • Should be Empty: