Healthcare Patient Health Questionnaires

HEALTHCARE PATIENT HEALTH QUESTIONNAIRE

Patient Information

Date of Birth:   Gender: Male Female Other Prefer not to say

Insurance Information

Emergency Contact

Medical History

Please list all current medications, including dosage and frequency.

Allergies (medication, food, environmental). Specify reaction and severity.

Prior surgeries or hospitalizations (include approximate dates).

Chronic conditions (e.g. diabetes, hypertension). Provide diagnosis date if known.

Select any of the following conditions that apply to you:

Diabetes   Hypertension   Heart disease   Asthma   Cancer

Bleeding disorder   Mental illness   Kidney disease   Liver disease   None of the above

Review of Systems

Please indicate current symptoms you are experiencing:

Fever or chills   Unintended weight loss   Fatigue   Chest pain   Shortness of breath

Palpitations   Cough   Abdominal pain   Nausea or vomiting   Diarrhea

Skin rash   Joint pain   Headaches   Dizziness   Other:

Lifestyle

Tobacco use: Current Former Never

Alcohol use: None Social Regular

Illicit drug use: Yes No

Immunizations

Please indicate vaccinations received and provide most recent date if known.

Influenza   Date:
COVID-19   Date:
Tdap/Tetanus   Date:

Consent and Certification

By signing below, I certify that the information provided on this form is true and complete to the best of my knowledge. I authorize the provider to render medical care as deemed necessary and to release medical information to insurers and other entities as required for billing and treatment. I understand that I retain the right to withdraw authorization in writing, except to the extent that action has already been taken in reliance on this authorization.

I authorize the clinic to communicate with me at the address and phone number provided and to leave messages regarding appointments, test results, and billing where permitted by law. I acknowledge that I am responsible for charges not covered by insurance and that the clinic will act on my behalf in billing third-party payers as necessary.

I consent to evaluation and treatment.
I authorize release of medical information for insurance billing and payment.

Privacy Acknowledgment

I acknowledge that I have received or been offered a copy of the practice's Notice of Privacy Practices describing how my health information may be used and disclosed, and my rights with respect to that information under applicable privacy law. I understand I may request restrictions on certain uses and disclosures, and that such requests will be considered in accordance with law.

I acknowledge receipt of the Notice of Privacy Practices.

Authorization to Release Medical Records

I hereby authorize the release of my medical records to the individual or organization named below for continuity of care and billing purposes. This authorization includes, but is not limited to, diagnostic reports, treatment summaries, and billing records. I understand this authorization will expire on the date entered below unless revoked earlier in writing.

Additional Notes

Use this space to record any additional information you believe is relevant to your care.

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