Healthcare Health Survey

HEALTHCARE HEALTH SURVEY

Purpose: This Health Survey collects medical, social, and insurance information necessary for assessment, treatment planning, and billing. Complete all sections to the best of your knowledge. If a question does not apply, enter N/A. The information provided will be used in accordance with applicable privacy and confidentiality rules.

Patient Information

Patient Name:    Date of Birth:    Sex/Gender:

Insurance Information

Medical History

Please check any conditions you have been diagnosed with:

Family & Social History

Family history of significant conditions (check all that apply):

Tobacco use: Current    Former    Never

Review of Systems / Current Symptoms

Check any symptoms you are currently experiencing:

Mental Health & Safety Screening

Have you experienced thoughts of harming yourself or others in the past 12 months?   Yes    No

Authorization & Acknowledgements

I certify that the information provided on this Health Survey is true and complete to the best of my knowledge. I understand that omission or falsification of information may affect care decisions. I authorize the use and disclosure of my health information for purposes of treatment, payment, and health care operations consistent with applicable privacy laws. I understand that I may receive the practice's privacy notice describing how my protected health information may be used and disclosed.

I consent to routine contacting by telephone, text message, or email regarding appointments, treatment, and billing unless I indicate otherwise in writing.

By signing below I affirm that I have read and understand this survey and the information contained herein and consent to the collection and use of this information as described. This authorization will remain in effect until the expiration date indicated above or until I revoke it in writing, except to the extent that action has already been taken in reliance on this authorization.

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