Medical History Form

DATE

PROVIDER

PATIENT INFORMATION

Patient Last Name

Patient First Name

Initial

Nickname

DOB

Soc. Sec. #

Phone

Address

City

State

Zip

Optional: Are you Spanish/Latino?

Yes No

Race

African American or Black Asian Caucasian or White Hawaiian or Other Pacific Island Decline Other

If other, please specify

Patient Employed by

Occupation

Business Address

Business Phone

Who referred You?

Prior Primary Care Physician

In case of emergency, who should be notified?

Phone

SOCIAL HISTORY

How many children do you have?

What are the ages of your children?

Gender

Female Male Female to Male Male to Female

Language Preference

English Spanish Other

If other, please specify

Marital Status

Single Married Divorced Widowed Domestic Partner

Lives

Alone Spouse Family

Exercise

Yes No

If yes, how often?

Tobacco use

Yes No

If yes, please specify

Pipe

Cigars

Cigarettes

Smokeless

Alcohol use

Yes No

If yes, how often?

Daily Occasional

Drug use

Yes No

If yes, please describe

Seatbelt use all the time?

Yes No

ADVANCE DIRECTIVE

Advanced Directive discussed?

Yes No

Living Will?

Yes No

Power of Attorney?

Yes No

PRIMARY INSURANCE

Person Responsible for Account

Last Name

First Name

Initial

Relation to Patient

DOB

Soc. Sec. #

Phone

Address (if different from patient’s)

City

State

Zip

Person Responsible Employed by

Occupation

Business Address

Business Phone

Insurance Company

Group #

Policy#

Names of other dependents covered under this plan

Add name(s) of other dependent(s)

ADDITIONAL INSURANCE

Is patient covered by additional insurance?

Yes No

Subscriber Name

Relation to Patient

DOB

Phone

Address (if different from patient’s)

City

State

Zip

Subscriber Employed by

Business Phone

Insurance Company

Soc. Sec. #

Group #

Policy#

Names of other dependents covered under this plan

Add name(s) of other dependent(s)

ASSIGNMENT AND RELEASE

I understand that I am financially responsible for all charges whether or not covered by insurance.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Responsible Party Name

Relationship

Date

I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Responsible Party Name

Relationship

Date

Notice of Privacy Practices

(Patient Initials)

I acknowledge that I have received the practice’s Notice of Privacy Practices, which describes the ways in which the practice may use and disclose my healthcare information for its treatment, payment, healthcare operations, and other described and permitted uses and disclosures. I understand that I may contact the Privacy Officer designated on the notice if I have a question or complaint. To the extent permitted by law, I consent to the use and disclosure of my information and for the purposes described in the practice’s Notice of Privacy Practices.

Release of Information

(Patient Initials)

I understand that under the Health Insurance Portability and Accountability Act of 1996(HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: * Conduct, plan and direct my treatment and follow-up care among the multiple healthcare providers who may be involved in that treatment directly or indirectly. * Obtain payment from designated third-party payers. * Conduct normal health care operations such as quality assessments or evaluations and physician certifications. I understand that I may request in writing that this organization restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand the organization is not required to agree to my requested restrictions, but if the organization does agree, then it is bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time.

Disclosures to Friends and/or Family Members

I give permission for my Protected Health Information to be disclosed by phone, fax or in person for purposes of picking up prescriptions, communicating results, findings, and care decisions to the family members and others listed below:

Add authorized person(s)

**This release will remain in effect until it is revoked in writing by the patient**

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Name of Patient or Personal Representative

Date

FAMILY HISTORY (check all that apply)

Deceased

Mother

Father

Sibling

Grandparent

Heart Disease

Mother

Father

Sibling

Grandparent

Diabetes

Mother

Father

Sibling

Grandparent

Stroke

Mother

Father

Sibling

Grandparent

Breast Cancer

Mother

Father

Sibling

Grandparent

Colon Cancer

Mother

Father

Sibling

Grandparent

Kidney Disease

Mother

Father

Sibling

Grandparent

Liver Disease

Mother

Father

Sibling

Grandparent

Mental Illness

Mother

Father

Sibling

Grandparent

Pancreatic Disease

Mother

Father

Sibling

Grandparent

Thyroid Disease

Mother

Father

Sibling

Grandparent

ALLERGY LIST

Add allergy

MEDICATION REVIEW (Dose, Frequency, Route)

(Please specify if over-the-counter, prescription, vitamin(s), herbal)

Add medication review

CHRONIC CONDITIONS

If Cancer is selected, please list

If Chronic Kidney Disease is selected, please specify

Stage I (GFR 90+) Stage II (GFR 60-89) Stage III (GFR 30-45) Stage IV (GFR 15-29) Stage V (ESRD)

If COPD / Emphysema is selected, please specify

with exacerbation without exacerbation

If Diabetes Mellitus is selected, please specify

without Complications with Complications with Opthalmic Disease with Renal Disease with Neuropathy with PVD Long Term Use of Insulin

If Fracture is selected, please specify

Vertebral Femur Pelvic

If Hypertension is selected, please specify

with CHF with Kidney Disease

If Malignancy is selected, please specify

If Other is selected, please specify

SURGERY HISTORY

SPECIALIST OR OTHER TREATING PHYSICIAN(S)-CARE PROVIDER(S)

Add specialist/physician/care provider

Your information will be encrypted.