Patient Intake and Consent Form

Patient Intake and Consent Form

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements began April 14, 2003. Many of these policies have long been part of our office practice. This form is a “friendly” version; a more complete text is posted in the office.What This Is All About:HIPAA sets rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not limit the normal interchange of information required to provide you with quality care. HIPAA provides rights and protections for you as a patient, while allowing us to maintain effective care and communication. For more information, visit www.hhs.gov.
PATIENT DETAILS
First Name*
Last Name*
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemaleOther
Street Address*
City*
State*
ZIP Code*
Home Phone*
Please enter a valid phone number.
Mobile Phone*
Please enter a valid phone number.
State Issue ID or DL*
Issuing State*
E-Mail*
example@example.com
Weight (lbs)*
Height (inches)*
Emergency Contact Name*
Relationship*
Emergency Contact E-Mail*
example@example.com
Emergency Contact Home Phone*
Please enter a valid phone number.
Emergency Contact Mobile Phone*
Please enter a valid phone number.
ALLERGIES

List your allergies and describe the reactions to your body:
Allergy
Reaction
Allergy
Reaction
Allergy
Reaction
Allergy
Reaction
MEDICATION

List all the medications and/or supplements that you are currently taking including thedosage.
Medication/Supplement
Dose
Medication/Supplement
Dose
Medication/Supplement
Dose
Medication/Supplement
Dose
Medication/Supplement
Dose
Medication/Supplement
Dose
FAMILY HEALTH HISTORY

List any major conditions/illnesses that your immediate family members have had:

Family Health History*

	Condition	Living?	If deceased at what age?
Mother
Father
Sibling
Other
Other

SURGICAL HISTORY

List any surgeries, fractures, major illnesses, or hospitalizations that you have had:

Surgical History*

	Description	Doctor	Location	Year
1
2
3
4
5
6

MEDICAL HISTORY

Have you ever had any of the following?*

	Yes/No
Anemia
Hypertension
Arthritis Conditions
Asthma
Male Hypogonadism
Atrial Fibrillation
Bleeding Problem
Hypothyroidism
Benign Prostatic Hyperplasia
Infection Problems
Coronary Artery Disease
Cancer
Insomnia
Cardiac Arrest
Irritable Bowel Syndrome
Celiac Disease
Kidney Problems
Congestive Heart Failure
Menopause
Chronic Fatigue Syndrome
Migraines/Headaches
Depression
Osteoporosis
Diabetes Type 1
Pulmonary Embolism
Diabetes Type 2
Seizure Disorders
Drug/Alcohol Abuse
Stroke
Erectile Dysfunction
Syndrome X
Fibromyalgia
GERD
Hyperinsulinemia
Hyperlipidemia

HEALTH CONCERNS
What’s your primary health concern/goal? *
Do you have pain?*

YesNo
If yes, where?
How has pain changed?*

IncreasedDecreasedUnchanged
Do you consume alcohol?*

YN
How many drinks per week
Do you smoke?*

YN
What do you smoke?*

TobaccoMarijuanaOther
Specify other
Frequency of smoking*

DailyWeeklyOccasionallyRarely
Do you use other drugs?*

YN
What other drugs?
How often?

DailyWeeklyOccasionallyRarely
Do you drink caffeine?*

YN
Exercise frequency*

DailyWeeklyOccasionallyRarely
Are you on a special diet?*

YN
What diet?
Planning pregnancy?*

YN
Pregnant now?*

YN
Type of contraception
When was your last menstrual cycle?

MonthDayYear
Date
TICK IF THIS APPLIES TO YOU

ConstipationFatigue/ changes in energy levelsUnable to lose weightShortness of breath with exercising, or ambulationLack of interest in sexDifficulty in sleeping, staying asleep / falling asleep Concentration & brain fogMore emotional than normalIncrease in joint painAbnormal weight gainMen: Difficulty in getting or sustaining an erectionDecrease in muscle strength andenduranceWoman : vaginal drynessPainful intercourseNight sweatsIrritable/anxiousHeadaches
Our Office Policies:
1. Confidentiality: Your information will be kept confidential except as necessary for treatment, payment, or healthcare operations.
2. Communication: We may contact you for appointment reminders or updates via phone, email, or mail.
3. Vendors: Approved vendors with limited access to PHI must follow HIPAA confidentiality standards.
4. Inspections: Government or insurance representatives may review PHI as required by law.
5. Complaints: You may bring privacy concerns to the attention of the office manager or doctor.
6. No Marketing Use: Your PHI will not be used for marketing, advertising, or product promotion.
7. Patient Access: You have the right to review or request copies of your medical records.
8. Policy Updates: We may revise policies to better serve patients and maintain compliance.
9. Restrictions: You may request limits on how we use or share your PHI, though we are not obligated to adopt all requests.
I have read and understand the HIPAA Information Form and agree to its terms.
This consent remains in effect until revoked in writing.
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Consent Date*

MonthDayYear
Date
Print Name
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Patient Intake and Consent Form

PATIENT DETAILS

ALLERGIES

MEDICATION

FAMILY HEALTH HISTORY

SURGICAL HISTORY

MEDICAL HISTORY

HEALTH CONCERNS