Healthcare Lifestyle Answers

HEALTHCARE LIFESTYLE ANSWERS

Patient Information

Date of Birth:    Gender: Female Male Other

Insurance Information (if applicable)

Medical History (high-level)

Lifestyle: Tobacco, Alcohol, Substances

Do you currently use tobacco products? Yes No    If yes, type:    Frequency:

Alcohol use: None Social Regular    Typical amount:

Nutrition, Exercise & Sleep

Typical diet:

Exercise:

Typical sleep duration:    Sleep quality: Good Fair Poor

Mental Health & Stress

Sexual & Reproductive Health

Sexually active: Yes No    Contraception method:

Safety & Social Determinants

Housing stability: Stable Unstable    Transportation concerns: Yes No

Patient Acknowledgment and Authorization

I certify that the information provided in this Healthcare Lifestyle Answers form is complete and accurate to the best of my knowledge. I understand that the clinical team will use these responses to inform treatment, preventive services, and referrals. I acknowledge that omissions or misrepresentations may affect the appropriateness of care provided.

I authorize the use and disclosure of the health information supplied here for purposes of treatment, care coordination, and healthcare operations within this practice and to other providers engaged in my care. This authorization does not extend beyond treatment-related uses and disclosures except as required or permitted by law.

I understand that I may withdraw this authorization at any time by providing written notice, except to the extent that action has already been taken in reliance on it. Withdrawal will not affect disclosures made prior to receipt of the written revocation.

HIPAA / Privacy Acknowledgment

I acknowledge that I have been provided with information regarding how my protected health information may be used and disclosed for treatment, payment, and health care operations and that the practice maintains policies to protect confidentiality. I understand my rights regarding access to my records, amendment requests, and accounting of disclosures as provided under applicable privacy laws.

By signing below I expressly consent to the collection and documentation of the lifestyle, medical, and social information contained in this form. I consent to be contacted for follow-up care, appointment reminders, and care coordination as necessary, unless I have indicated otherwise in writing.

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