GENERAL NEW PATIENT FORM
| HEALTH HISTORY & AUTHORIZATION - PAGE THREE |
ARE YOU TAKING ANY OF THE FOLLOWING MEDICATIONS?
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NERVE PILLS
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PAIN KILLERS (INCLUDING ASPIRIN)
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MUSCLE RELAXERS
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STIMULANTS
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BLOOD THINNERS
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TRANQUILIZERS
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INSULIN
OTHER (S): __________________________________________________________________________________________
HAVE YOU EVER HAD ANY OF THE FOLLOWING DISEASES / MEDICAL CONDITIONS?
Y N HEART ATTACK / STROKE
Y N HEART SURGERY / PACEMAKER
Y N HEART MURMUR
Y N CONGENITAL HEART DEFECT
Y N MITRAL VALVE PROLAPSE
Y N ARTIFICIAL VALVES
Y N ALCOHOL / DRUG ABUSE
Y N VENEREAL DESEASE
Y N HEPATITIS
Y N HIV+ / AIDS
Y N SHINGLES
Y N CANCER
Y N FREQUENT NECK PAIN
Y N EMPHYSEMA / GLAUCOMA
Y N ANEMIA
Y N HIGH / LOW BLOOD PRESSURE
Y N PSYCHIATRIC PROBLEMS
Y N RHEUMATIC FEVER
Y N SEVERE / FREQUENT HEADACHES
Y N KIDNEY PROBLEMS
Y N ULCERS / COLITIS
Y N FAINTING / SEIZURES / EPILEPSY
Y N SINUS PROBLEMS
Y N ASTHMA
Y N DIABETES / TUBERCULOSIS
Y N DIFFICULTY BREATHING
Y N CHEMOTHERAPY
Y N LOWER BACK PAIN
Y N ARTIFICIAL BONES / JOINTS
Y N ARTHRITIS
PLEASE LIST ANY OTHER SERIOUS MEDICAL CONDITION (S) YOU HAVE OR EVER HAD: _______________________________________
___________________________________________________________________________________________________________________
PLEASE LIST ANYTHING THAT YOU MAY BE ALLERGIC TO: _____________________________________________________________
___________________________________________________________________________________________________________________
LIST ALL PREVIOUS SURGERIES / TREATMENTS WITH DATES: ___________________________________________________________
___________________________________________________________________________________________________________________
LIST ANY AND ALL ACCIDENTS WITH DATES: __________________________________________________________________________
____________________________________________________________________________________________________________________
DO YOU EXERCISE REGULARLY?
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NO
| __ |
YES / HOW MUCH? _______________ HOW LONG? _______________
DO YOU SMOKE?
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NO
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YES / HOW MUCH? _______________ HOW LONG? _______________
ARE YOU OR DO YOU WEAR:
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HEEL LIFTS
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SOLE LIFTS
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INNER SOLES
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ARCH SUPPORTS
WHAT IS THE AGE OF YOUR MATTRESS? _______________ IS IT COMFORTABLE? __ YES __ NO
FOR WOMEN: ARE YOU TAKING BIRTH CONTROL? __ YES __ NO
ARE YOU PREGNANT? __ NO __ YES / HOW LONG? _______________ NURSING? __ YES __ NO
WE INVITE YOU TO DISCUSS WITH US ANY QUESTIONS REGARDING OUR SERVICES. THE BEST HEALTH SERVICES ARE
BASED ON A FRIENDLY, MUTUAL UNDERSTANDING BETWEEN PROVIDER AND PATIENT.
BASED ON A FRIENDLY, MUTUAL UNDERSTANDING BETWEEN PROVIDER AND PATIENT.
OUR POLICY REQUIRES PAYMENT IN FULL FOR ALL SERVICES RENDERED AT THE TIME OF VISIT, UNLESS OTHER
ARRANGEMENTS HAVE BEEN MADE WITH OUR BUSINESS MANAGER. IF ACCOUNT IS NOT PAID WITHIN 90 DAYS OF THE
DATE OF SERVICE AND NO FINANCIAL ARRANGEMENTS HAVE BEEN MADE, YOU WILL BE RESPONSIBLE FOR ANY
EXPENSES INCURRED IN COLLECTING YOUR ACCOUNT.
ARRANGEMENTS HAVE BEEN MADE WITH OUR BUSINESS MANAGER. IF ACCOUNT IS NOT PAID WITHIN 90 DAYS OF THE
DATE OF SERVICE AND NO FINANCIAL ARRANGEMENTS HAVE BEEN MADE, YOU WILL BE RESPONSIBLE FOR ANY
EXPENSES INCURRED IN COLLECTING YOUR ACCOUNT.
I AUTHORIZE THE STAFF TO PERFORM ANY NECESSARY SERVICES NEEDED DURING DIAGNOSIS AND TREATMENT. I
ALSO AUTHORIZE THE PROVIDER TO RELEASE ANY INFORMATION REQUIRED TO PROCESS INSURANCE CLAIMS.
ALSO AUTHORIZE THE PROVIDER TO RELEASE ANY INFORMATION REQUIRED TO PROCESS INSURANCE CLAIMS.
I UNDERSTAND THE ABOVE INFORMATION AND GUARANTEE THIS FORM WAS COMPLETED CORRECTLY TO THE BEST OF
MY KNOWLEDGE AND ABILITY AND I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO INFORM THIS OFFICE OF ANY
CHANGES IN MY MEDICAL STATUS.
MY KNOWLEDGE AND ABILITY AND I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO INFORM THIS OFFICE OF ANY
CHANGES IN MY MEDICAL STATUS.
I HEREBY AUTHORIZE ASSIGNMENT OF MY INSURANCE RIGHTS AND BENEFITS DIRECTLY TO THE PROVIDER FOR SERVICES
RENDERED (IF OFFERED AT THIS OFFICE).
RENDERED (IF OFFERED AT THIS OFFICE).
SIGNATURE __________________________________________________ DATE __________/__________/__________
PRINT NAME __________________________________________________
