INT-02 · about 10 minutes
Please complete this form before your consultation so your doctor has your full history. Check the box for anything that applies to you, even if it is well controlled. If you are not sure, leave it blank and ask the doctor. This form is part of your medical record.
Your answers are encrypted in this browser before they are sent. Only SSMC clinic staff, using the clinic’s private key, can read them. Staff add them to your medical record and then delete them from this website; anything not deleted is erased automatically after 30 days. Nothing is saved on this device after you close the page.
Fields marked * are required. Everything else: answer what you can; if you are not sure, leave it blank and ask the doctor.
Check any condition you have now or have had in the past.
Check any surgery or procedure you have had.
Check if a close blood relative (parent, brother, sister, child) has had any of the following.
Check anything you have noticed recently (in the past few weeks). This helps your doctor decide whether any symptom needs attention before a procedure. If you check any item shown in bold, please tell the front desk or nurse right away — these may need to be looked at before your procedure.
To the best of my knowledge, the information on this form is complete and accurate. I understand that incorrect information can be dangerous to my health, and it is my responsibility to inform the office of any changes.
After you submit, this form cannot be opened again from your link.
These forms need JavaScript to encrypt your answers. Please turn it on, or ask the clinic for paper forms.
Secure patient forms
Encrypted on your device
Secure patient forms
Encrypted on your device