Health History Form

Traveling out of town and need to make an unexpected trip to the urgent care? Share your Health History form with the urgent care so that they have your list of diagnoses and medications. 

 

 

Health History Form is an interactive list of diagnosis and medications that you can share. Your Health Score will generate based on your diagnoses and demographic details. 

Note: If you have enrolled via your My Medicare account, a list of diagnosis and medications will auto-generate based on your claims data. 

Managing Diagnoses 
 

Step 1. Self report a diagnosis by clicking on Add Diagnosis

 

Step 2. Enter the name or code of the diagnosis then click the Search icon.

 

Step 3. A list of matching items will generate, click the desired diagnosis name. A management status menu will then appear for you to choose options such as, managing or not managing. Add any specific details you would like to notate for yourself, family and doctors to know about the diagnosis. Click Save.

 

Step 4. Click on a desired diagnosis to edit the status and/or notes.


 

Managing Medications 

Step 1. Self report medications by clicking on Add Medication

Step 2. Enter the name of the medication then click the Search icon

Step 3. A list of matching items will generate, click the desired medication name. Status options will appear for you to choose whether yes, taking or no, not taking. Add specific notes about the medication such as the dosage and how often you are taking the medication. 

Export a PDF 
Print a copy of your Health History Form to share with family, doctor's and caregivers. 

Share Via Link 

Generate a link that can be shared to doctors, urgent cares, family, and caregivers. 

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Scottsdale, AZ  85255

1.888.862.0366

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