gordonmerkle.com - Confidential Patient Information

Confidential Patient Information
Name:
Date:

MonthDayYear
Date
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Home:
Please enter a valid phone number.Format: (000) 000-0000.
Phone Work:
Please enter a valid phone number.Format: (000) 000-0000.
Phone Cell:
Please enter a valid phone number.Format: (000) 000-0000.
Fax:
Email:
example@example.com
Age:
Birthdate:

MonthDayYear
Date
Height:
Weight:
SS#:
Marital Status:
Spouse's Name:
Name, ages of children:
Occupation:
Employer:
Who should we thank for referring you?
Emergency Contact:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Physician:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Medical History
List all medications and supplements currently used:
List all accident, surgeries or hospitalizations (with dates):
List all allergies and/or food sensitives you have:
Current Health Condition
What do you feel are the main contributing factors to your health complaints?
Have any of these conditions been treated in the past? Give doctor names, diagnosis and therapy.
Shade in any areas of discomfort on the diagram below
Past Medical and Family History

Select (Yes/No) of the following health conditions ever experienced by you or your family member and indicate the person involved:

Rows	No	Yes	If yes, indicate family member
Aids/HIV
Arthritis
Asthma
Anemia
Alcoholism
Allergies
Auto Immune
Cancer
Chronic Fatigue
Depression
Diabetes
Drug Addiction
Eczema/Psoriasis
Epilepsy/Seizures
Glaucoma
Headache/Migraines
Heart Disease
Hepatitis
Hypertension
Hypozincemia
Kidney/Bladder
Liver/Gallbladder
Mental Illness
Neurological
Rheumatic Fever
STD
Stroke
Suicide
Thyroid
Tuberculosis
Parasites
Ulcer

Other:
What is the date of your most recent blood test?

MonthDayYear
Date
When did you last have a complete physical?

OFFICE POLICIES
Patient is responsible for full payment on day of treatment unless other arrangements have been made. All supplements must be paid for before they leave the office.

HEALTH INSURANCE: Patient is expected to pay in full at the time of service. We will give you the necessary forms to enable you to collect payment from your insurance company. It is the patient's responsibility to verify your coverage benefits with your insurance carrier.

PERSONAL INJURY: When personal injury and auto accident cases are being treated we will bill your med-pay or insurance directly. Before accepting liens of any kind, we will discuss the case and contact your attorney directly.

WORKER'S COMPENSATION: Patient must provide us with an authorization signed by your employer or supervisor authorizing acupuncture medical services on your first visit. It is the patient's responsibility to provide us with the name and address of the worker's compensation carrier. We will process all forms and bill your employer's carrier directly.

MISSED APPOINTMENTS: UNLESS CANCELLED AT LEAST 24 HOURS IN ADVANCE, OUR POLICY IS TO CHARGE THE NORMAL RATE FOR THE VISIT.
Please help us serve you better by keeping your scheduled appointments.

I understand and agree that and services rendered me are charged directly to me and that I am responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees owed for services will be immediately due and payable. By signing this I agree to the above as well as give full consent to authorize treatment to be given me.
Signature of patient or responsible party:

Clear
Date:

MonthDayYear
Date
Should be Empty:

Confidential Patient Information

Medical History

Current Health Condition

Past Medical and Family History

Metabolic Assessment Form

PART I

PART II

Category I

Category II

Category III

Category IV

Category V

Category VI

Category VII

Category VIII

Category IX

Category X

Category XI

Category XII

Category XIII

Category XIV

Category XV

Category XVI

Category XVII

PART III

OFFICE POLICIES