Today's Date:
Who is Responsible for your care:
SelfPOA-Power of Attorney
Last Name:
First Name:
Middle:
Sex:
FM
DOB:
SS#:
Marital Status:
SingleMarriedDivorceWidow
Race:
AsianWhiteAfrican AmericanHispanicAmerican IndianOther
Ethnicity:
HispanicNon-Hispanic
Language:
EnglishSpanishFrenchGermanChineseJapaneseKoreanArabicRussianOther
Address:
Email Address:
Phone:
Cell:
Emergency Contact:
Relationship: RelationshipSelfSpousePOAOther
Emergency Contact Phone:
Preferred Pharmacy and Location:
Preferred Pharmacy Phone #:
Power of Attorney:
POA Relationship: RelationshipSelfSpousePOAOther
Person Completing this Form:
Apt.#:
City:
State:
Zip Code:
Date of Birth:
Relationship to patient: RelationshipSelfSpousePOAOther
Phone #:
*You must provide a copy of your insurance cards OR fill in your primary and secondary insurance information*
Primary Insurance Co:
Subscriber Name:
Relationship to Subscriber:
Subscriber SS#:
Subscriber DOB:
Subscriber Phone:
ID#:
Group#:
Effective Date:
Claims Address:
Secondary Insurance Co:
Accept payment of benefits directly from your insurance company under the terms of your insurance. Release medical records to your insurance, hospitals, any physician, and attorneys for the purpose of determining benefits, coordination of care, or legal matters.
Obtain necessary information from your other health care providers.
Your signature below also indicates your acknowledgement that you have been provided with a copy of the Notice of Privacy Practices Policy (HIPAA), and that your answers regarding permission to contact authorized individuals is accurate.
Signature:
Date:
Responsible Party Signature:
Patient Name:
Patient DOB:
Current Primary Care Physician:
Physician Address:
List any medical supplies you use:
Are you actively receiving Home Health Care (Nursing, Therapy, etc.)?
NoYes
Name of Agency:
Vaccine
Yes
No
Date Of Vaccination
Pneumonia
Shingles
Tetanus or Tdap
Flu
COVID
COVID Booster
List all medication allergies:
List all other allergies (food, tape, etc.):
Patient Height:
Patient Weight:
ADHDAlcoholismAllergiesAnemiaAnxietyArrhythmiaArthritisAsthmaBipolarBladder ProblemsBleeding ProblemsCancer
Crohn’s DiseaseCOPD/EmphysemaDementiaDepressionDiabetes 1 or 2DiverticulitisDVT (Blood Clot)GERO (Acid Reflux)GlaucomaHeadachesHeart DiseaseHeart Attack
Hiatal HerniaHigh Blood PressureKidney StonesKidney DiseaseHigh CholesterolHIVHepatitisIrritable Bowel (IBS)LupusLiver DiseaseMacular DegenerationNeuropathy
Osteopenia/OsteoporosisParkinson’s DiseasePeripheral Vascular DiseasePeptic UlcerPsoriasisPulmonary Embolism (PE)Rheumatoid ArthritisSeizure DisorderSleep ApneaStrokeThyroid DisorderUlcerative Colitis
Please provide a brief history of the above checked items (Time frame, location of the issue, etc.):
Have you ever used tobacco products (including smokeless)? NoYes
(If Yes) - What type of product?
Are you currently using tobacco products? NoYes
If no:
How many years ago did you quit?
How many years did you use?
How much did you use per day? packs/cans/vapor pens
If yes:
How many years have you used?
How much per day? packs/cans/vapor pens
How many years?
]
Do you drink beer, wine, or liquor? NoYesFormerly
(If yes) - How often do you drink? DailyWeeklyMonthlyYearly
- When was your last drink?
- Amount you consume in one sitting:
- Have you ever attended alcohol rehabilitation? NoYes
- Has anyone ever been concerned about your drinking? NoYes
(If formerly) - What year did you quit?
Do you currently use any recreational drugs (marijuana, Cocaine, etc.)? YesNoFormerly
(If Yes or Formerly) - What type(s) of drug?
When did you start/stop?
Please list all medications that you use: Include prescription, non-prescription and Natural products (Insulin, Inhalers, vitamin supplements, etc.)
*You may attach a printed list of medications from previous provider if available*
Current Medication Used
Strength
How do you use it? (How many? How many times a day? Skip dosed?)
Please check all that apply to immediate family (i.e. Mother, Father, Siblings, Grandparents):
Disease
If so, whom?
Breast Cancer
Colon Cancer
Other types of cancer
High Blood Pressure
Stroke
Heart Problems
Diabetes
Type of Surgery
Date of Surgery
Surgeon
Please list additional medical providers involved in your healthcare (e.g., Cardiologist, Mental Health Provider, Kidney Doctor, etc.):
Physician Name: Physician Specialty:
If you have any questions regarding this form, please contact us at (865) 298-1500. Thank you for your time and we look forward to meeting you.
