Patient Intake Form

First Name *

Last Name *

Address *

City *

State *

Postal code *

Cell Phone *

Home Phone:

Email *

SS #/SIN:

DOB:

Gender:

Male

Female

Employer Name:

Occupation:

Spouse's Name:

Spouse's DOB:

Whom may we thank for referring you?

Person to contact in case of an emergency:

Emergency Contact Phone:

Relationship to Patient:

Responsible Party's Information

Name of The Person responsible for this account:

Relationship to Patient:

Address:

Home Phone:

Cell Phone:

Email:

Driver's License:

DOB:

ASSIGNMENT OF HEALTH PLAN BENEFITS AND RIGHTS AS WELL AS AN APPOINTMENT AND/ OR DESIGNATION AS MY PERSONAL REPRESENTATIVE AND AN ERISA/PPACA REPRESENTATIVE AND BENEFICIARY

I understand and agree that (regardless of whatever health insurance or medical benefits I have), I am ultimately responsible to pay HARBOUR MEDICAL CENTERS as well as all employees, employers, representatives, and agents thereof, (hereinafter collectively referred to as "Healthcare Provider") the balance due on my account for any professional services rendered and for any supplies, tests, or medications provided. I hereby authorize payment of, and assign my rights to, any health insurance or medical plan benefits directly to Healthcare Provider for any and all medical/healthcare services, supplies, tests, treatments, and/or medications that have been or will be rendered or provided; as well as designating and appointing Healthcare Provider as my beneficiary under all health insurance or medical plans which I may have benefits under. I hereby authorize the release of any health status, conditions, symptoms or treatment information contained in your records that is needed to file and process insurance or medical plan claims, to pursue appeals on any denied or partially paid claims, for legal pursuit as to any unpaid or partially paid claims, or to pursue any other remedies necessary in connection with same. I hereby assign directly to Healthcare Provider all rights to payment, benefits, and all other legal rights under, or pursuant to, any health plan (including, but not limited to, any ERISA governed plan/insurance contract, PPACA governed plan/insurance contract) rights that I (or my child, spouse, or dependent) may have under my/our applicable health plan(s) or health insurance policy(ies). I also hereby appoint and designate that Healthcare Provider can act on my/our behalf, as my/our Personal Representative, ERISA Representative, and PPACA Representative as to any claim determination, to request any relevant claim or plan information from the applicable health plan or insurer, to file and pursue appeals and/or legal action (including in my name and on my behalf) to obtain and/or protect benefits and/or payments that are due (or have been previously paid) to either Healthcare Provider, myself, and/or my family members as a result of services rendered by Healthcare Provider, and to pursue any and all remedies to which I/we may be entitled, including the use of legal action against the health plan, the insurer, or any administrator. I hereby also declare that Healthcare Provider is my/our beneficiary regarding my/our health plan as contemplated by both ERISA and PPACA, and that Healthcare Provider can pursue any and all rights that I/we may have under state and/or federal law regarding my/our health plan. This assignment, appointment, and designation will remain in effect unless revoked by me in writing. It is my intent that the effective date of this document shall relate back to include all services, supplies, test, treatments, or medications that have been previously provided by Healthcare Provider. A photocopy or scan or this document is to be considered as valid and as enforceable as the original.

Patient Signature:

Clear

Signature of Guardian if applicable:

Clear

Signed This Date:

Health History

Chief Complaint:

Where is the pain/problem?

Quality of Pain:

Severity of Pain:

Duration of Pain/Problem:

Timing of Pain/Problem:

Context of Pain/Problem:

Associated Signs/Symptoms:

Modifying Factors:

Have you had steroid injections?

Yes

If yes, when was your most recent?

Please List Any Other Disease/Conditions We Should Know About:

Date of Last Chest X-Ray (If Applicable):

Are you pregnant?

Yes

Date of last Menstrual Cycle?

Have You Ever Had Cancer?

Yes

What type of Cancer? (If Applicable)

Date of Cancer Remission:

Have You Ever Received An Organ Transplant?

Yes

What Type of Organ Transplant Have You Received?

Please List Previous Hospitalizations/Surgeries/Serious Illnesses:

When?

Hospital, City, State:

List Any Current Medications Include Nonprescription:

Have you ever taken Fen-Phen/Redux?

Yes

Do You Have Any Allergies To Medication?

Yes

If Yes, What Medication?

Use of Alchohol

Never

Rarely

Moderate

Daily

Use of Tobacco

Never

Rarely

Moderate

Daily

Use of Drugs

Never

Rarely

Moderate

Daily

Drug Use - List Type/Frequency if Applicable:

Indicate which of the below you have experienced in the last 1-2 months. Leave blank if not applicable.

Asthma

Stuffy Nose

Hay Fever

Sore Throat

Chronic Cough

Chest Congestion

Frequent Sneezing

Itchy/Watery Eyes

Drainage

Earache or Ear Infection

Itching

Hoarseness

Shortness of Breath

Wheezing

Muscle Aches

Fibromyalgia

Arthritis

Joint Pain

Low Back Pain

Neck Pain

Wrist/Hand Pain

Elbow Pain

Shoulder Pain

Pain Between Shoulder Blades

Hip Pain

Knee Pain

Ankle/Foot Pain

Headaches

Migraines

Dizziness

Tingling

Pins/Needles in Hands or Feet

Fatigue

Malaise

Weakness, Tiredness

Lightheadedness

Constipation

Irritability

Diarrhea

Feeling Foggy

Forgetfulness

Family Medical History:

Father Age:

Father - List Any Disease Experienced:

Father - If Deceased, Cause of Death:

Mother Age:

Mother - List Any Disease Experienced:

Mother - If Deceased, Cause Of Death:

Siblings Age(s):

Sibling(s) - List Any Disease Experienced:

Sibling(s) - If Deceased, Cause Of Death:

Childern(s) Age:

Children(s) - List Any Disease Experienced

Children(s) - If Deceased, Cause Of Death:

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor's office of any changes in my medical status. I also authorize the healthcare staff to perform the necessary services I may need.

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES FOR HARBOUR MEDICAL CENTERS

I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read them or declined the opportunity to read them and understand the Notice of Privacy Practices. I understand that this form will be placed in my patient chart and maintained for six years.

I Authorize to Be Contacted for Apppointment Reminders, Follow-Up Calls via the Following Channels:

Mail

Texts

Calls to Cell Phone

Calls to Home Phone

By initialing the line below I authorize the doctor to personally discuss with me products that may benefit my health or condition.

Clear

List below the names and relationships of people to whom you authorize the Practice to release PHI:

Signature of Patient, Parent, Guardian or Patient's Legal Representative

Clear

Date Signed