LOVING HEART HOME CARE LLC
HIPAA COMPLIANCE FORM (All provided information will be treated with confidentiality.
BASIC INFORMATION
Full Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date
-
Month
-
Day
Year
Date
Gender
Female
Male
Marital Status
Single
Married
Widowed
Divorced
Weight
In kilogram
Height
In cm
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EMERGENCY CONTACT INFORMATION
Emergency Contact Full Name
First Name
Last Name
Relationship
Emergency Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Next
MEDICAL HISTORY
Please answer all questions to the best of your ability.
Check the conditions that apply to you or to any of your immediate family member or relatives:
Asthma
Cancer
Cardiac Disease
Diabetes
Hypertension
Psychiatric Disorder
Epilepsy
Other
If other, please specify:
Check the symptoms that you're currently experiencing:
Chest pain
Respiratory
Cardiac Disease
Cardiovascular
Hematological
Lymphatic
Neurological
Psychiatric
Gastrointestinal
Genitourinary
Weight gain
Weight loss
Musculoskeletal
Other
If other, please specify:
Are you currently taking any medication?
Yes
No
If Yes, please list it here:
Please list all medications (DRUG NAME, DOSE, FREQUENCY, ROUTE) that you arecurrently prescribed, if more than one, separate them with a comma.
Do you have any medication allergies?
Yes
No
Not sure
Do you use or do you have history of using tobacco?
Yes
No
Do you use or do you have history ofusing illegal drugs?
Yes
No
How often do you consume alcohol?
Daily
Weekly
Occasionally
Never
I hereby acknowledge that all the information provided in this HIPAA form is accurate and complete to the best of my knowledge.
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