Healthcare Medical History Exam

Healthcare Medical History Exam

Patient Information

Male Female Other Prefer not to say

Emergency Contact

Insurance Information

Clinical Information

No known drug allergies Known allergies (see details)

Diabetes Hypertension Heart disease Stroke Asthma / COPD Kidney disease Liver disease Thyroid disorder Cancer Depression / Anxiety

Social & Lifestyle History

Current Former Never

None Social Daily

Yes No

Review of Systems

Check symptom categories that apply or leave blank if none:

Constitutional (fever, weight loss, fatigue) Eyes ENT (ears, nose, throat) Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Neurological Psychiatric Endocrine Hematologic / Lymphatic Allergic / Immunologic

Legal Acknowledgments & Authorizations

By signing below I certify that the above information is accurate and complete to the best of my knowledge. I understand that deliberate omission or falsification of medical history may adversely affect my care and coverage.

I authorize the healthcare providers and staff to perform diagnostic and therapeutic procedures as deemed necessary in the course of my care. I authorize release of my medical information and records to my insurance carrier and other health care providers for purposes of treatment, payment and health care operations.

This authorization for release of protected health information expires on: . I understand that I may revoke this authorization at any time by providing written notice, except to the extent that action has been taken in reliance on this authorization.

I acknowledge that I have been offered an opportunity to review the practice's Notice of Privacy Practices and that I understand my rights regarding the use and disclosure of my protected health information.

HIPAA Acknowledgment: I acknowledge receipt / offer of the Notice of Privacy Practices.

Authorization to Release: I authorize release of relevant medical information for treatment and billing purposes.

If this form is being signed by a legal representative or guardian, the representative affirms that they are authorized to execute this document on behalf of the patient and will provide documentation of legal authority upon request.

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