Healthcare Wellness Form

HEALTHCARE WELLNESS FORM

Patient Information

Patient Name:

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

Emergency Contact

Insurance Information

Medical History

Please check all conditions that apply:

Hypertension Diabetes Heart disease Asthma

Cancer Thyroid disease Kidney disease Autoimmune disorder

Depression / Anxiety None of the above

Lifestyle and Preventive Health

Tobacco use: Current Past Never

Alcohol use: None Social Regular

Review of Systems (check if present)

Fever or chills Unexplained weight loss Fatigue

Chest pain or palpitations Shortness of breath Dizziness

Consent for Routine Wellness Care and Release

I hereby authorize the clinical staff to perform routine wellness evaluations, examinations, immunizations and diagnostic procedures as clinically indicated. I understand that the practice will obtain my informed consent for any procedures that carry significant risk or that are not routine. I authorize release of medical information necessary for treatment, payment, and healthcare operations to my health insurer and other providers as required for continuity of care.

I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on this authorization. Revocation must be submitted to the clinic in writing and will not affect disclosures made prior to receipt of the revocation.

By checking this box I consent to routine wellness care and release of information as described above.

HIPAA Notice Acknowledgment

I acknowledge receipt of the clinic's Notice of Privacy Practices that explains how my medical information may be used and disclosed, and how I can obtain access to this information. I understand my rights with respect to protected health information and that I may request restrictions in writing.

I acknowledge that I have received and reviewed the Notice of Privacy Practices.

Authorization to Share Information

I authorize release of pertinent medical information to the following individual(s) for coordination of care and appointment information. I understand this authorization will remain in effect until revoked in writing.

Certification

I certify that the information I have provided on this form is true and correct to the best of my knowledge. I understand that withholding information could be harmful to my care. I agree to notify the clinic of any changes in my health status, medications, or insurance coverage.

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