Please fill out EVERY PAGE of the Patient History packet. There are 5 pages in this Patient History packet. Every section of the packet must be filled out completely. This information is confidential. Both the nursing staff and Dr. Knutson must have a complete history to fully understand why you/ the patient are being seen in our office. Also, we ask the every patient, both NEW AND ESTABLISHED, fill out the packet annually; as personal information such as medication, surgeries, procedures, etc. may have changed. Please print these forms and fill them out completely prior to your appointment.
REMINDER: AFTER YOU PRINT OFF THESE FORMS, YOU MUST ALSO PRINT THE OFFICE POLICY FORM, DEMOGRAPHICS AND HIPAA FORM, AND THE PATIENT DISCLOSURE FORM. These forms will be located on the Patient Portal page.
Patient History Form, Page 1 of 5
Patient History Form, Page 2 of 5
Patient History Form, Page 3 of 5
Patient History Form, Page 4 of 5