Healthcare Deep-Dive Wellness Form

Healthcare Deep-Dive Wellness Form

Patient Information

Full legal name:

Date of birth:    Gender (check all that apply): Female Male Non-binary Prefer not to say

Emergency Contact

Insurance Information

Subscriber date of birth:

Medical History

Primary care provider:    Last visit (approx.):

Lifestyle & Social History

Tobacco use: Never Current Past

Alcohol use: None Social Daily Frequency/details:

Typical sleep duration:

Mental Health

Recent mood concerns: Depression Anxiety High stress

Currently receiving mental health treatment: Yes No Provider name (if applicable):

Suicidal ideation or self-harm thoughts in the past year: Yes No

Review of Systems (current concerns)

Please check any current problems: Constitutional (fever, weight change) Head/Eyes/Ears/Nose/Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Neurologic Endocrine Skin

Preventive Care & Screenings

Last annual physical:    Last blood work:

Last mammogram (if applicable):    Last colonoscopy (if applicable):

Consent, Authorization, and Acknowledgment

Consent to treatment: I consent to routine examinations, diagnostic procedures, and treatments determined by my provider to be medically necessary. I understand that no guarantee can be made as to the results of care provided. I authorize clinicians to perform examinations and treatments appropriate to my condition, and to document findings in my medical record.

Authorization for release of information: I authorize the release of my protected health information for purposes of treatment, billing, and health care operations to my insurance company and to other providers involved in my care. This authorization includes release of information necessary to process claims and coordinate care.

Right to revoke: I understand that I may revoke this authorization at any time in writing, except to the extent that action has already been taken in reliance on this authorization. Revocation does not affect disclosures made prior to receipt of the revocation.

Communication preferences: I authorize clinic staff to communicate appointment reminders, test results, and other health information via the following channels (check all that apply): Phone Email SMS/text message

Authorization expiration date:    (If left blank, this authorization remains valid until revoked in writing.)

HIPAA Privacy Acknowledgment

I acknowledge that I have received or been offered the Notice of Privacy Practices describing how my medical information may be used and disclosed, and how I can obtain access to this information. I understand that the clinic is committed to protecting my privacy and that I may request additional restrictions on uses and disclosures of my health information.

I acknowledge receipt of the Notice of Privacy Practices and understand my rights.

Certification

I certify that the information I have provided on this form is true and complete to the best of my knowledge. I understand that providing inaccurate or incomplete information may affect clinical decisions and insurance claims. I agree to notify the clinic of any changes to my medical history, medications, insurance, or contact information.

I certify the foregoing statements and disclosures are accurate.

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