Healthcare Provider History

HEALTHCARE PROVIDER HISTORY

Patient Information

Patient Name:    Date of Birth:    Gender:

Insurance & Referral

Reason for Visit & Presenting Problem

Medical History

Hypertension    Diabetes Mellitus    Coronary/Heart Disease    Asthma/COPD    Kidney Disease

Family & Social History

Tobacco use:    Alcohol use:    Recreational drugs:

Review of Systems

Please check symptoms you currently have or have had recently:

Fever/chills    Unexplained weight loss    Chest pain    Shortness of breath    Cough

Abdominal pain    Nausea/vomiting    Bowel habit changes    Urinary symptoms    Headache

Functional Status & Preventive Care

Activities of daily living:    Mobility aid:

Do you have advance directives?    Yes    No

Patient Authorization & Acknowledgments

I certify that the information provided on this form is complete and accurate to the best of my knowledge. I understand that withholding information or providing false information may adversely affect my care. I authorize the healthcare provider and staff to perform diagnostic and therapeutic procedures as necessary for my care, and to obtain, use and disclose my protected health information for treatment, payment, and healthcare operations consistent with applicable law.

I authorize the release of medical information to other treating providers, insurance carriers, and persons identified by me when necessary for care coordination. This authorization expires on: unless revoked earlier in writing.

I acknowledge receipt of the practice's Notice of Privacy Practices and understand my rights regarding the privacy of my health information.

By signing below I consent to the above authorizations and acknowledgements. If signing as a legal guardian, parent, or authorized representative, I certify that I have the legal authority to do so and identify my relationship to the patient in the field below.

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