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Health History Update

For returning patients: tell us what has changed since your last visit.

Please think about your health since your last visit with us. Your clinician will go over any changes with you.

Patient Name *

Date of Birth *

Email *

Since your last visit *

No changes since my last visit

Something has changed

New or changed medical conditions, diagnoses or hospital stays

New, stopped or changed medicines (including supplements)

New allergies or reactions

Anything else that has changed (for example, a new doctor, surgery or pregnancy)

New address, phone, email or insurance

This update is accurate to the best of my knowledge. *

By signing below, you confirm the information you gave is accurate to the best of your knowledge and you agree to sign this form electronically. Your electronic signature has the same effect as a handwritten one. You can ask Style 2 Demo for a paper copy of this form at any time.

Date *

Signature *

Your information is encrypted and transmitted securely under HIPAA.

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