No appointment needed, get care now

(559) 227-2273 Get directions

Accident Recovery Pain Relief Injury Rehabilitation Same-Day Illness & Injury Ongoing & Preventive Care

Women's Health Urgent Care Accident & Injury Treatment Chiropractic Care & Rehabilitation Primary Care

Our Story Clinic Tour Patient Stories Careers

Telemedicine Patient Forms Health & Recovery Tips Referrals

Location & Contact

Health History Form | First Health Medical Center in Fresno

Help us understand your health before your visit

Past and current conditions, medications and allergies. Your provider reviews this before your visit so your time in the room is spent on you.

Patient details

1

Patient details

First name*

Last name*

Date of birth*

Phone*

Height

Weight

Medical history

2

Medical history

Conditions you have now or have had

High blood pressureDiabetesHeart diseaseAsthma or COPDThyroid conditionArthritisCancerAnxiety or depressionSeizuresKidney or liver disease

Other conditions or ongoing problems

Past surgeries and approximate dates

Significant family medical history

Medications & allergies

3

Medications & allergies

Current medications and doses*

Allergies (medication, food, latex)*

Lifestyle

4

Lifestyle

Tobacco or vaping use

NeverFormerCurrent

Alcohol use

NoneOccasionalWeeklyDaily

Are you pregnant or possibly pregnant?

NoYesNot applicable

Anything else we should know?

Signature and consent

Signature & consent

Type your full name as your signature*

Date*

I confirm this history is accurate to the best of my knowledge and authorize First Health Medical Center to use it in providing my care.

Having trouble? Print the PDF version instead, or call (559) 227-2273 and our front desk will take your details by phone.

A family-founded walk-in medical center serving Fresno, Clovis and the Central Valley since 1989. Urgent care, accident and injury treatment, chiropractic care and primary care under one roof.

7161 N Howard St #100, Fresno, CA 93720
(559) 227-2273
Monday – Friday, 8:00am – 6:00pm

Services

Women's Health
Urgent Care
Accident & Injury Treatment
Chiropractic Care & Rehabilitation
Primary Care

Treatments

Accident Recovery
Pain Relief
Injury Rehabilitation
Same-Day Illness & Injury
Ongoing & Preventive Care

About

Our Story
Clinic Tour
Patient Stories
Careers

Resources

Telemedicine
Patient Forms
Health & Recovery Tips
Referrals

© 2026 First Health Medical Center. All rights reserved.

Privacy Policy Terms of Service Notice of Privacy Practices Medical Disclaimer