NEW PATIENT HEALTH HISTORY QUESTIONNAIRE

Patient File #:

Today's Date

WELCOME: The doctor and staff welcome you and want to provide you with the best possible care. We will conduct a thorough history and physical examination to decide if we can assist. If we do not believe that your condition will respond to our care, we will refer you to the appropriate healthcare provider. If you are a candidate for care in this office, then a treatment plan will be recommended to fit your individual needs.

INSTRUCTIONS: Please complete the following information in its entirety. The information submitted on this form is strictly confidential. If you have difficulty understanding any portion of this form, please ask for assistance. If the question does not pertain to you, simply write N/A for non-applicable.

PERSONAL INFORMATION:

First Name

Middle Name

Last Name

Suffix

Address:

City:

State:

Zip:

Birth Date:

Age:

Cell Phone:

Email address

Spouse's Name:

Is your spouse a patient in our office?

Yes No

Employer/ Employment Status Employed: Unemployed Full Time/ Part Time Other

Business Name:

Occupation/Job Title:

Business Phone:

Type of Work:

May we contact you at work?

Yes No

Emergency Contact Information

Name:

Relationship:

Cell Phone:

Address:

City:

State:

Zip:

Payment/Insurance Information:

Is the condition(s) that brought you here today due to an automobile accident?

Yes No

Is the condition(s) that brought you here today due to on the job/worker compensation injury?

Yes No

Is the condition(s) that brought you here today due to any type of accident or trauma?

Yes No

If yes to any of the above, please contact office first at 833-8100. Explain the accident/injury here:

Who besides yourself is responsible for your bill?

Self-Pay

Health Insurance

Workers Comp

Auto Insurances

Other

If other, please specify:

Personal Health Insurance Carrier:

Health ID Card #:

Insured Person's Name:

Group #:

Insured Person's Date of Birth:

Auto or Workers' Comp insurance Carrier and Claim #:

Primary Complaint:

When did it start?

Describe the condition:

What do you think caused the problem?

Rate the pain from 1-10

At its worse

At present time

At least severe

Does the pain travel?

Yes No

If yes, from where to where

Is the condition getting worse?

Yes No

List the activities that this condition prevents you from doing?

List past treatment for this condition and if they helped

LIST MEDICATIONS, VITAMINS, SUPPLEMENTS:

LIST PAST TRAUMA, ACCIDENTS, INJURIES, HOSPITALIZATIONS, SURGERIES:

LIST FAMILY HISTORY, SOCIAL HISTORY, EXERCISE LEVEL, SMOKING, STRESS LEVEL:

Is there any other information that you feel would be relevant to your current condition(s) that was not covered? Please explain in the following section any information that you feel would be helpful to the doctor.

AUTHORIZATION FOR RELEASE OF INFORMATION:

I authorize the release of any medical information necessary to process my insurance claims.

AUTHORIZATION OF ASSIGNMENT:

I authorize payment of medical benefits to (Please input Name below) for services rendered to me.

REIMBURSEMENT POLICY:

We often do not know exactly what your insurance company will pay us until we receive payment. Either way, we usually accept their payment after any deductible, co-payment and co-insurance is handled. Please understand that your insurance is an agreement between you and your insurance company, and all services rendered to you are ultimately your responsibility.

ACCEPTANCE AS A PATIENT:

I understand and agree that this office has the right to refuse to accept me as a patient at anytime before treatment begins or terminate my care as a patient if in the course of treatment if I am not following the treatment plan for my condition or be referred out to another health care provider as the doctor deems medically necessary. I understand that the taking of a history and the conducting of a physical examination are not considered treatment but are part of the process of information gathering so that the doctor can determine whether to accept me as a patient.

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

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Signature

Date

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