Spring Hill Primary Care
Fields marked with an asterisk (*) are required. Name * Date *
Today's Date
Patient First Name *
Middle Name
Patient Last Name *
SR / JR / Other
Preferred Name (if different)
Sex * MaleFemale
Date of Birth *
Social Security Number Address *
Insurance *
Member ID# *
Home Phone *
Cell Phone
Work Phone
Email Address * Marital Status * MarriedSingleSeparatedDivorcedWidow
Who was your previous medical doctor? * Doctor Address Doctor Phone *
Name * Relationship Address Phone Number *
Please tick this box if it does not apply.
Allergies
Reaction
Name
Dose
Start
End
Prescribed By
Procedure
Year
Where
Physician
Eye Exam
Labs
Colonoscopy
Mammogram
Gynecological Exam
Pap Smear
Last Menstrual Cycle
Pregnancies
Births
Miscarriages
Bone Density
Prostate Exam
Prostate Specific Antigen (PSA)
YesNo
Vaccine
Date
Tetanus
Influenza Vaccine
Zostavax
Shingles
Meningitis
Yellow Fever
Polio
Pneumonia Vaccine
Hep A
Hep B
COVID19 Vaccine
Relation
Details
Mother
Father
Do you smoke? YesNo Years Smoking Packs per Day
YesNo Type BeerWineLiquor Drinks per Week
YesNo Needle Use YesNo
YesNo Number of Partners Partner Gender MaleFemale Birth Control NoneCondomPill/Patch/IUDVasectomyTubal
YesNo Exercise Type Duration
Hours per Night Sleep Problems YesNo
Specialist
Last Visit
Cardiology
Dermatology
Other 1
Other 2
Question
Response
Have you had any falls in the past year?
How many falls?
Do you have any fractures due to a fall?
Where are they located?
If you are having pain at this time, what is your pain scale?
1–10
Where is the pain?
Do you use medical equipment supplies at home?
What type of equipment?
Do you have a medical living will?
Do you have a power of attorney?
Who is your power of attorney?
Do you have a hearing problem?
Which ear? LeftRightBoth
Activity
Yes / No
Meal Preparation
Doing Housework
Dressing Yourself
Bathing Yourself
Eating
Walking
Transportation
Have you had any surgeries? Medical History
Full Name Signature (Type Name) *
Current Medical Conditions
1.
2.
3.
4.
5.
Please List Below If You Have Any Other Medical Conditions.
Any Questions Or Concerns For Dr. Kolli? *
What Pharmacy Would You Like To Use For Prescriptions?
(Can be changed at any time)
Name:
Street Address:
City / State / Zip:
Phone Number: