Midtown Medical and Wellness Center Form

Patient Name

Date

DOB

SS #/SIN

Home phone

Cell Phone

Patient's Address

City

State

Zip

Employer Name

Spouse or Patient's Guardian name

Spouse's Employer

Whom may we thank for referring you?

Person to contact in case of an emergency

Phone

In case of a medical emergency, if the patient is of school age 15+, is ok to treat in my absence.

Parent or Guardian

Date

Responsible Party

Name of The Person responsible for this account

Relationship to Patient

Date of Birth

Address

Email address

Home Phone

Cell Phone

Driver's License #

if yes, complete the following:

Name of the insured

Relationship to patient

Birthdate

SS#/SIN

Name of Employer

Work Phone

Address of Employer

State

Zip

Insurance Company

Group #

Union or local #

Ins. Co. Address

City

State

Zip

ASSIGNMENT OF HEALTH PLAN BENEFITS AND RIGHTS AS WELL AS AN APPOINTMENT AND/OR DESIGNATION AS MY PERSONAL REPRESENTATIVE AND AN ERISA/PPACA REPRESENTATIVE AND BENEFICIARY

Before signing, please read our Assignment of Health Plan Benefits.

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.

Signed this

day of

Patient Signiture

Patient Print/Signature of Guardian if applicable

Health History

Patient Name

DOB

Date

Chief Complaint:

History of Present illness

Location

(Where is the pain/problem?)

Quality

(Example: normal vs abnormal color, activity, etc .. )

Severity

(How severe is the pain/problem on a scale of 1-10 with 10 being the most severe?)

Duration

(How long have you had this pain/ problem? When did it start?)

Timing

(Does the pain/problem occur at a specific time?)

Context

(Where were you at the onset of this pain/problem?)

Associated Signs/Symptoms

(What other associated problems have you been having?)

Modifying Factors

(What makes the pain/problem worse or better? Have you had previous episodes?)

Past Medical History

Please list all diseases or illnesses that you previously had.

Please list all previous hospitalizations/surgeries/serious illnesses that you previously had.

If there are any, please indicate the dates as well the hospital name and the and state where the facility is located.

Medication: (include nonprescription)

if yes what type

Patient Social History

Type/Frequency

Excessive Exposure

CLINICIAN SIGNATURE

DATE REVIEWED

PATIENTNAME

Date

Name

DOB

Date

Family Medical History:

Father

Age

Disease

If Deceased, Cause Of Death

Mother

Age

Disease

If Deceased, Cause Of Death

Siblings

Age

Disease

If Deceased, Cause Of Death

Add more sibling

Spouse

Age

Disease

If Deceased, Cause Of Death

Children

Age

Disease

If Deceased, Cause Of Death

Add more children

Please list any illnesses or issues you have experienced in the last 1-2 months and indicated how often it occurs by following the guide below.

1=Never; 2=Rarely; 3=Occasionally; 4=Frequently; 5=Constantly

Eyes/Ears/Nose/Throat/Respiratory

Muscular/Skeletal

Neurological

General

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor's office of any changes in my medical status. I also authorize the healthcare staff to perform the necessary services Imay needs.

Signature of the Patient, Parent or Guardian

Date

Patient/Client Rights and Responsibilities

Before signing below, please read our Patient/Client's Rights and Responsibilities.

I have read and understood my rights and responsibilities.

Before signing below, please read our Patient/Client's Rights and Responsibilities.

Patient Signature

Date

MEDICAL CONSENT TO TREAT

Before signing below, please read our Medical Consent to Treat.

Patient/Guardian Signature

Date

Witness Signature

Date

Patient's Printed Name / Signature

Patients DOB

Signature of Person Authorized to Consent for Patient. Relationship to Patient:

Parent Guardian Spouse

Signature

Your information will be encrypted.