Healthcare Extended Questionnaire

HEALTHCARE EXTENDED QUESTIONNAIRE

This Healthcare Extended Questionnaire collects medical, social, and demographic information to assist in clinical assessment, planning, and continuity of care. All responses should be accurate and complete. Patient Name: Date of Birth:

Patient Information

Gender: Male Female Other/Prefer not to say

Emergency Contact

Insurance Information

Current Medications & Allergies

Medical & Surgical History

Please indicate whether you have ever been diagnosed with any of the following conditions (check all that apply):

Diabetes Hypertension Heart disease Asthma / COPD

Kidney disease Liver disease Cancer Bleeding disorder

Family & Social History

Tobacco use: Current Former Never

Alcohol use: None Social Regular

Mental Health & Functional Status

Have you ever been diagnosed with a psychiatric condition? Yes No

Current Symptoms / Chief Complaint

Pain: current level 0 (none) to 10 (worst): Duration of current symptoms:

Preventive Care & Immunizations

Authorizations, Certifications, and Acknowledgments

By signing below, I certify under penalty of perjury that the information provided on this form is true and complete to the best of my knowledge. I authorize my healthcare providers to access and review the health information provided herein for purposes of diagnosis, treatment, care coordination, and insurance claims. I understand that this information may be shared with other healthcare professionals involved in my care as permitted by law and institutional policy.

I further authorize the release of medical records and clinical information necessary for treatment, payment, or healthcare operations. This authorization is voluntary and may be revoked in writing at any time, except to the extent action has already been taken in reliance on it. The revocation does not affect disclosures already made in accordance with this authorization. This authorization expires on the date specified below or one year from the date of signature if no expiration date is provided.

I acknowledge receipt of the provider's privacy practices and understand my rights with respect to my health information. I understand I may request a copy of my records and that reasonable fees may apply for copies as permitted by law.

Patient Certification

I acknowledge that I have provided the above information voluntarily and that omissions or false statements may affect my care. I understand that this questionnaire complements clinical evaluation and does not replace professional medical advice.

Sign Now