Last Name First Name MI. Date of Birth / / Sex: M / F Social Security Marital Status. o o o o

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1 Ph: Fax: PATIENT DEMOGRAPHICS Last Name First Name MI Date f Birth / / Sex: M / F Scial Security Marital Status Race (check all that apply) American Indian r Native Alaskan Asian Native Hawaiian r Other Pacific Islander African American White Hispanic Other Refuse t Reprt Ethnicity (please select ne) Hispanic r Latin Nt Hispanic r Latin Refuse t Reprt Primary Language If yur primary language is NOT English: D yu require an interpreter? (please circle) YES NO Address Preferred Telephne # ( ) Secndary Telephne # ( ) Please circle yur cell phne preference: Vice Text Hw did yu hear abut ur ffice? EMERGENCY CONTACT / FAMILY INFORMATION Emergency Cntact Name Relatinship t patient Emergency Cntact Telephne # ( ) May we Release Medical Infrmatin t yur Emergency Cntact? (please circle ne) YES NO Spuse s Name Spuse s Telephne # ( ) May we Release Medical Infrmatin t yur Spuse? (please circle ne) YES NO Parent r Legal Guardian Name (Minrs nly) Telephne # ( ) PATIENT PHARMACY INFORMATION Primary Pharmacy Name Telephne # ( ) Secndary Pharmacy Name Telephne # ( ) REASON FOR VISIT What is the reasn fr yur visit tday? -Paper wrk cntinued n page 2-

2 -Patient Infrmatin page 2- EMPLOYMENT / INSURANCE INFORMATION Type f Emplyment Wrk Telephne # ( ) Is it k t cntact yu at wrk? (please circle ne) YES NO FOR EMERGENIES ONLY Current Insurance Cmpany Relatinship t the Plicy Hlder -PLEASE PRESENT YOUR INSURANCE CARD TO THE FRONT OFFICE AT THE TIME OF YOUR VISIT- ALLERGIES Please list all medicatins yu are allergic: Please list all ther allergies yu have: CURRENT MEDICATIONS Please list all medicatins yu are currently taking ( bth prescribed and ver the cunter) -Paper wrk cntinued n page 3-

3 -Patient Infrmatin page 3- PAST MEDICAL HISTORY Please circle all that apply: Diabetes Current Past N/A Hypertensin Current Past N/A Other (please explain belw) When was yur last Dental Exam? When was yur last Eye Exam? When was yur last Tetanus Sht? Fr Children under 6 years f age: Des the child live in r spend time in a building that was built prir t 1960 r that has peeling paint? YES NO Is the child in a state funded prgram? YES NO SURGICAL HISTORY Please list all surgeries and their dates: FAMILY MEDICAL HISTORY Please list any family members with the fllwing: Diabetes Hypertensin Cancer (please list type as well) Other (please list cnditin and relatin) SOCIAL HISTORY D yu use Alchl? YES NO If yes, please indicate the type, amunt & frequency f use. D yu use Tbacc? YES NO If yes, please indicate the type, amunt & frequency f use. D yu use any illegal drugs? YES NO If yes, please indicate the type, amunt & frequency f use. TUBERCULOSIS (TB) RISK SCREENING Are yu a health care prvider? YES NO D yu have cntact with a persn knwn t have TB? YES NO D yu have cntact with a hmeless, illegal drug user r migrant wrker? YES NO D yu live in r visit a grup hme r prisn? YES NO Have yu spend extended time in Asia, Africa r Suth America? YES NO -Paper wrk cntinued n page 4-

4 ADVANCED DIRECTIVE STATUS - Patient Infrmatin page 4- An Advanced Directive is a dcument that allws yu t give instructins abut yur health care r name anther persn t make health care decisins fr yu. This practice respects yur right t make yur wn health care decisins. We cmply with state and federal laws regarding advanced health care directives. We d nt discriminate against anyne based n the status f their Advanced Directive. Patient Last Name First Name MI Date f Birth / / D yu have an Advanced Directive? YES NO If yes, please list wh has a cpy belw. Wuld yu like t receive infrmatin abut Advanced Directives? YES NO FOR OFFICE USE ONLY: Patient was given infrmatin n Advanced Directives? YES NO Patient prvided an Advanced Directive fr their medical recrd? YES NO Staff signature Date / / CONSENT FOR USING AND PROCTECTING HEALTH CARE INFORMATION -Privacy practices are psted in the patient waiting area. Yu may request a printed cpy. May this ffice call the telephne numbers listed n page 1 and leave a vice message regarding yur appintments and medical care? (please circle ne) YES NO May this ffice send mail t the address listed n page 1 regarding yur appintments and medical care? (please circle ne) YES NO My prtected health infrmatin will be used strictly t carry ut my treatment, health care peratins and receive payment fr medical services prvided. Patient Name Patient Signature OR Parent/Legal Guardian Name Parent/Legal Guardian Signature I have the right t refuse t sign abve and nt allw this practice t use my prtected health infrmatin t carry ut my treatment, healthcare peratins and receive payment fr medical services prvided. My healthcare prvider may cnsider this request but is nt required t agree. If the prvider des nt agree with yur request, yu will be given 30 days t secure a new medical prvider. Medical recrds will be cpied upn request. -Paper wrk cntinued n page 5-

5 IMMUNIZATIONS - Patient Infrmatin page 5- Immunizatin recrds are needed fr all patients. Please prvide yur immunizatin recrd r request a cpy frm yur previus prvider. Recrds requests are available in the frnt ffice. FINANCIAL AGREEMENT Please prvide yur insurance card, c-pay and valid state ID at the time f yur visit. A pht ID will be taken and attached t yur medical recrd. All unpaid insurance claims and balances will be billed t the patient. AUTHORIZATION TO BILL INSURANCE I authrize the practice t send medical claims, medical infrmatin and cllect payment frm my insurance carrier. I will prvide a cpy f prf f insurance fr bth ffice visits and pharmacy benefits if under a separate plan. CONSENT TO TREAT I give my cnsent fr a medical examinatin, evaluatin, treatment and review f my prescriptins. I have the right t understand and agree t my plan f care. I have the right t refuse care. I have the right t request language interpretatin. Patient Name Patient Signature OR Parent/Legal Guardian Name Parent/Legal Guardian Signature -Please cmplete the attached Staying Healthy assessment fr yur age grup-