New Patient Health History Form

In order to provide you the best possible wellness care, please complete this form

Patient Data

Mailing Address

Current Complaints

Insurance Information

*If an auto accident, please provide:

Signatures

Name of the Insured _____________________________________________

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Patient's signature _______________________________________________

Date ____________________

Spouse's or guardian's signature __________________________________

Date ____________________

Medical History

Have you ever:

Family History

Habits

Have you ever suffered from:

Medical Symptoms

Rate each of the following symptoms based upon your typical health profile for the past 30 days. Please use the following point scale:

0 - Never or almost never have the symptom

1 - Occasionally have it; effect is NOT severe

2 - Occasionally have it; effect IS severe

3 - Frequently have it; effect is NOT severe

4 - Frequently have it; effect IS severe

Office Polices

We invite you to discuss with us any questions regading our services. The best health services are basd on a friendly, mutual understanding between provider and patient.

Our policy requires payment in full fo all services rendered at the time of visit, unless other arrangements have been made with the 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 late fees, legal fees, collection agency fees, interest charges and any other 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.

I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes to the information I have provided.

Enter the verification code in the box below.