New Patient History Form - Dignity Health - dignityhealth 2026

1. Click ‘Get Form’ to open the New Patient History Form in the editor.
2. Begin by entering your child's name, date of birth (DOB), and medical record number (MRN) at the top of the form.
3. In the 'What brings you in today?' section, select any relevant reasons for your visit, such as a move or insurance change.
4. Provide details about your child's prior healthcare by filling in the doctor's name and clinic/organization. If applicable, indicate if you have medical records with you or plan to send them.
5. Complete the immunization section by answering whether your child has received immunizations and if you have their immunization record available.
6. List any allergies and medications your child is currently taking in the respective sections provided.
7. Fill out the medical history section, indicating any past health issues or hospitalizations. Be sure to provide explanations where necessary.
8. For family history, detail who lives in your child's home and note any relevant family medical conditions.
9. If applicable, complete the newborn section for children up to 4 months old with information regarding birth weight and prenatal care.

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