Borland-Groover Clinic PATIENT GENERATED MEDICAL HISTORY Name: DOB: Primary Care Physician: Pharmacy: Pharmacy Phone #:

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Borland-Groover Clinic




COPD Emphysema Blood Transfusion Date: Cancer:

Congestive Heart Failure Coronary Artery Disease

Crohns Disease Ulcerative Colitis Diabetes Mellitus: Type 1 Type 2 Gallstones


High Blood Pressure Irritable Bowel Syndrome Liver Disease


Peptic Ulcer Disease Polyps

Sleep Apnea CPAP machine Y / N Other ALLERGY REACTION No known allergies Pancreatic Lung Cancer Ovarian Cancer Cancer Stomach Cancer Uterine Cancer Breast Cancer Colon Cancer Ca Esophageal ncer Kidney Cancer Liver Cancer Other Cancer


Working / Retired Tobacco Status: ❏ Former ❏ Never ❏ Current Type:______________ ❏ E-Cigs Qty/day_______ # Yrs__________Age started_____ Stopped_____

Alcohol: Y/N Drinks/Day Social

Former Yr. Stopped

Recreational Drug use: Y / N Type:

Marital Status: M S D W L

Children #: Y/N boys: girls:

Mother: Alive Y/N If no, cause

Father: Alive Y/N If no, cause Sister: Alive Y/N If no, cause Brother: Alive Y/N If no, cause

Other Diseases That Run In The Family:





Cancer, Breast Cancer, Colon Cancer, Ovary Cancer, Uterus Cancer Colon Polyps Crohn’s Disease Gallstones Liver Disease Pancreatic Dis. Ulcerative Colitis Ulcers P/M P/M P/M P/M P/M P/M P/M P/M P/M P/M P/M P/M RELATIONSHIP AGE

TYPE Paternal/Maternal



Artificial Heart Valve

Artificial Joint (specify______________)

Bowel Obstruction

Neck Artery/Vascular Surgery Pacemaker


Pancreat Surgery

Surgery for Reflux/Hiatal Hernia

Surgery for Ulcers



Bowel (repair/resection)

CABG/Heart Bypass Vessels

C Section

Gallbladder removal

Gastric Bypass

Hysterectomy Total Partial



Could you be pregnant? Y / N

Directions: Please circle any of the following you have personally had during your life:

Directions: Please circle any of the following

that exists in your family.



BGC-463 Rev. 04/16 1

Name: DOB: Email:


Place Sticker Here

Primary Care Physician: Referring:

Pharmacy: Pharmacy Phone #:


Borland-Groover Clinic

Drug Name Dosage Start Date Why do you take the medicine?




DIRECTIONS: Please list any over the counter or prescribed medications you currently take.



NO YES chills fever lack of energy weight loss

NO YES short of breath frequent cough wheezing

NO YES chest pain extremity swelling palpitations

NO YES nasal congestion sinus infection sore throat

NO YES abdominal pain change in bowel habits constipation diarrhea difficulty swallowing heartburn vomiting blood blood in stool loss of appetite black stool nausea reflux vomiting

NO YES painful urination blood in urine urinary frequency urinary incontinence

NO YES vaginal discharge

NO YES NO YES contact allergy hives itching rash NO YES cold intolerance excessive thirst heat intolerance

headache numbness tremors

sensation of room spinning

NO YES anxiety increased stress

NO YES NO YES NO YES back pain muscle pain joint pain asthma food allergies

altered/weakened immune system seasonal allergies

NO YES bloating

uncontrolled bowel movements gas hemorrhoids yellow skin painful swallowing rectal bleeding

easy bleeding easy bruising

enlarged lymph glands

Borland-Groover Clinic




Directions: Have you had any of the following in the last three months?





Payments made to Borland Gr


Clinic that ar

e not honor

ed by the bank will incur

a r

eturn check fee

of $50.00. If failur

e to pay check and fee within 15 days of r

eceiving r

eturn check notice fr

om Borland



Clinic account will be turned over

to the State




-Groover Clinic

Acknowledgement of Receipt of Notice

& PHI Disclosure Authorization

Pa tie n t’s Fu ll N am e Pa tie n t’s Da te o f B ir th 1. I he re by a uth ori ze Bo rla nd -Gr oo ve r C lin ic to us e or di sc los e pr ot ec te d he alt h inf or m atio n (P H I) ab ou t m e to th e fo llo w in g p er so n( s). Pl ea se w rit e “ N /A ” i n a ny o f t he 3 fi eld s b elo w if n ot po pu la te d w ith th e n am e o f a p er so n: Au th or iz ed In d iv id u al #1 Au th or iz ed In d iv id u al #2 Au th or iz ed In d iv id u al #3 Na m e Ad d re ss Ci ty , S ta te Zi p Ph on e Nu m b er 2. I un de rs ta nd th at th e in fo rm atio n u se d o r d is clo se d m ay b e s ub je ct to r e-di sc los ur e by the pe rs on or c la ss of pe rs ons or fa cil ity re ce ivi ng it, and w oul d the n no longe r be pr ot ec te d by fe de ra l pr iva cy re gul ati ons . 3. Th is au th or iz ati on e xp ires u po n w rit ten n oti ce fro m m e, an d m ay b e rev ok ed at an y t im e. R ev ocat io n m us t b e in wr iti ng a nd su bm itt ed to th e f oll owi ng a dd re ss : P riv ac y Of fic er , 4 80 0 B elf or t R d, Ja ck so nv ill e, F L 32256 . 4. I un de rs ta nd th at m y t re atm en t, p ay m en t, e nro llm en t, o r eli gib ili ty fo r be ne fit s w ill n ot be c ondi tione d on w he the r I sig n t his a uth ori za tio n. 5. NOT IC E : I a ck no w le dg e th at I h av e h ad th e o pp or tu nity to r ev ie w a c op y o f B G C ’s N otic e o f P riv ac y P ra ctic es (“ N oti ce ”). I un de rs ta nd th at I am re sp on sib le to re ad th is N oti ce a nd n oti fy B G C , in w ri tin g, of a ny re qu es t f or re stri cti on s i n t he u se o r dis clo su re o f m y P H I. I u nd er sta nd B G C h as th e r ig ht to re vis e t his N oti ce a t a ny tim e an d w ill p os t a co py o f t he cu rren t N oti ce in th e of fice in a vis ib le lo cat io n at al l ti m es an d o n t hei r w eb sit e at www. bo rla nd gr oo ve r.c om . B G C w ill p ro vid e m e w ith a c op y o f its m os t r ec en t N otic e u po n m y r eq ue st. 6. I un de rs ta nd th e m os t re ce nt ve rs io n o f t his fo rm re pla ce s a ny p re vio us v ers io ns o n f ile in m y B G C h ea lth re co rd . Pr ev io us v er sio ns w ill b e v oid ed a nd PH I r ele as e w ill b e b as ed o n t he cu rren t v er sio n o f t his au th or izat io n. __________________________________________ _______________________________ Si gn atu re o f Pa tie nt Da te o f Pa tie nt Si gn atu re OR ___________________________________ _______________________ __ _______ ______________________ Si gn atu re of Pa tie nt’ s Re pr es en ta tiv e Da te o f R ep re se nta tiv e’ s Si gn atu re De sc rip tio n o f Au th or ity to A ct fo r t he Pa tie nt


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