This is the first part of your history. Provide your social history below and we'll add on to it at your appointment. Only mark the checkboxes if it is a yes.
When you have finished this section, you will be prompted to go on to the next section. Remember, you can do it another time if you like, just go to http://onecircle.health/history.

Privacy is important, and these forms aren’t highly secured, so do not put your full name in! Rather, only enter your initials and the date of your upcoming visit. This way, the only people who would be able to connect the submitted information to you is us and you.

Enter only your initials

enter the date of your first appointment

(enter 'retired' or whatever reason you may be not working if that is the case)

(a brief summary of kinds of work you have done in the past, be sure to mention things that include exposure to chemicals like gas stations, mines, farms, labs, factories, etc.)

(please enter ages of any children, and just enter "alone" if no people or animals live with you)

(enter the numbers of animals you live with)

(start with things you're doing now, then things you enjoy but aren't actively doing now)

(what you're actually doing: kind, duration, frequency- "walk 30 min 2x/week", or just enter "none")

You can select more than one item using the control or command keys

1 serving is about a half cup or the size of a deck or cards

include water

(include "some college" or a degree, if you have)

1 drink is: 12oz beer, 6oz wine, or 1.5oz liquor

The next sections are shorter


You will be sent to the next section (of 3 total) after you submit this form. The others should be shorter.

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