Patient Intake Sheet

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Patient Intake Sheet

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Transcription:

Patient Intake Sheet Patient Information Name: Cell Phone: ( ) Address: Work Phone: ( ) Emergency Phone: ( ) Email Address: Date of Birth: Age: Who referred you? Weight: Height: Who is your primary care provider? Employer: Today s Date: Your Occupation: What is the medical reason that brought you to Arcadia Wellness Center? Medications: Allergies: Past Surgeries: Dates: General Health Questions Are you or might you be pregnant? Are you breastfeeding? Are you trying to become pregnant? Are there any other health concerns we should be made aware of?

Medical History: General: Fatigue Cancer Weakness Tremors Head, Eyes, Ears, Nose and Throat: Eye problems Ringing in ears Hearing problems Cardiovascular: Chest pain Poor circulation Heart attack Murmur Respiratory: Asthma Valley fever Tuberculosis Low Sex Drive Bruise easily Diabetes Other: Ear aches Sinus problems Headaches Irregular heartbeats Swelling in feet Pacemaker High cholesterol Short of breath Cough (Please mark all appropriate boxes) Insomnia Fevers Alcohol (Quantify ) Dental problems Thyroid problems Head injury Fainting High blood pressure Valve replacement Pneumonia Emphysema Gastrointestinal: Nausea/vomiting GI bleeding from meds Constipation Musculoskeletal: Neck pain Joint pain Osteoarthritis Renal: Kidney infections Hepatitis (Active? ) Neuropsychological: Depression Stress problems Reproductive: Low Libido Erectile Dysfunction Do you take any of the following: Antiobiotics Aspirin or Ibuprofen Blood Pressure Medication Back pain muscle Rheumatoid spasms Bursitis Kidney problems Anxiety Seizure disorder Vaginal Dryness Urinary Incontinence Anti-coagulants Coritsone or Steroids Insulin Tennis elbow Carpal tunnel syndrome Bladder infections Drug/alcohol abuse Pain during sex Anti-depressants Hormones/Contraceptives NSAIDS

Do you take any of the following: Sedatives Fish Oils Accutane in the past 12 months Thyroid Medication Tumeric Retin A Vitamin D Blood Thinners Other: Skin Care History: Have you had unprotected sun exposure or been in a tanning booth in the last 2 weeks? Are you planning a vacation in the sun in the next 2-4 months? Please list all injectable procedures (Botox, Filler, etc.) and dates performed: Any history of allergic or other reactions to a skin care product or treatment? If yes, please explain: Please indicate your current skin care products/regimen: Do you tan easily? Do you burn easily? Do you suffer from extreme sensitivity to sunlight? Ethnicity: Asian African American Caucasian Hispanic/Latino Pacific Islander Mixed Race Other Concerns: Dry Skin Brown Spots Fine Lines Oily Skin Redness Deep Wrinkles Acne/Breakouts Rosacea Skin Texture Scars Skin Care Products Facial Veins Thin Lips Nasolabial Creases Facial/Body Hair

Family History: Disease: Headaches Heart disease Stroke Diabetes High blood pressure Increased cholesterol Arthritis Rheumatoid arthritis Kidney problems Liver problems Seizures Osteoporosis Cancer Other medical problems: Which family member(s)? Consent for Treatment NAME DOB I, the undersigned, hereby authorize Sarah Quinn, FNP-C and whomever he/she may designate as his/her assistant(s) to perform diagnostic tests, and to administer treatment as necessary.i, also certify that no guarantee or assurance has been made to the results that may be obtained and release all liability related to care and that I have provided my complete health history, medications, and health concerns in the Patient Intake Form. I understand and agree that health insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that this office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to this office will be credited to my account upon receipt. I permit this office to endorse remittances for the conveyance of credit to my account. HOWEVER, I CLEARLY UNDERSTAND AND AGREE THAT ALL SERVICES RENDERED TO ME ARE CHARGED DIRECTLY TO ME AND THAT I AM PERSONALLY RESPONSIBLE FOR PAYMENT. Patient s Signature Date Witness

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