Date: ____________________

Last Name:________________________ First

Name:_________________________MI:______
Social Security # (SSI):_________________ DOB:______________
Nickname:______________
Address:_________________________________________________
APT#:_______________
City:______________________________ State:_______________
Zip:___________________
Home Phone #:__________________________ Work
Phone#:__________________________
Cell Phone#:_________________________
Preferred Contact Method: Home
I authorize voicemail messages: Yes

Work

Cell

No

Alternate Address:_________________________________________
APT#:_______________
City:______________________________ State:_______________
Zip:___________________
If alternate address is seasonal, please indicate the dates this address is to
be used:____________________________
Gender: Female

Male

Ethnicity:___________________ Race:_________________(Asian, Black, Hispanic,

White, etc.)
Insurance
Primary Insurance:___________________________ Member ID
#:_______________________
1

Insured Name:______________________________________
DOB:______________________
Insured SS#:________________________ Insured
Employer:____________________________
Employer
Address:______________________________________________________________
Plan Type: HMO
PPO
Open Access PCP
Name:_____________________________
Insurance Continued
Secondary Insurance:_________________________ Member ID
#:_______________________
Insured Name:______________________________________
DOB:______________________
Insured SS#:________________________ Insured
Employer:____________________________
Employer
Address:______________________________________________________________
Plan Type: HMO
PPO
Open Access PCP
Name:_____________________________
_____________________________________________________________________________
Emergency Contact
Emergency
Contact:_____________________________________________________________
Relationship:___________________________
Phone#:________________________________
Parent Information: Please be advised that minor children (under 18) will not
be treated without a legal guardian present. Legal guardian other than
parent must provide proof of guardianship. Please sign below:
Parents Printed Name:_______________________________
Relationship:________________

Parents Signature:___________________________________
Date:______________________
_____________________________________________________________________________
Medical History
What are you being seen for today?
_______________________________________________
_____________________________________________________________________________
Surgeries / Accidents / Hospitalizations:
Reason
Dates
________________________________________________
________________________
________________________________________________
________________________
________________________________________________
________________________
________________________________________________
________________________
________________________________________________
________________________
________________________________________________
________________________
________________________________________________
________________________
Allergies: Please list all allergies below and indicate the type of reaction.
Medication /
Reaction:__________________________________________________________
Food /
Reaction:_______________________________________________________________
Latex (Other materials) /
Reaction:_________________________________________________
3

All Patients: Do you have, or have ever had any of the following?
(Check all that apply)
NONE
Acid Refux Bulimia
Treatment

Hearing Problems Psychiatric

ADHD
Cancer/Malignancy
Radiation/Chemo

Heart Attack

AIDS/HIV
Cerebral Palsy
Respiratory Disease

Heart Disease

Anemia
Chemical Dependency Heart Murmur
Rheumatic Fever

Anorexia
Problems

Sinus

Anxiety

Chicken Pox
Convulsions

Artifcial Heart
Disease

Depression

Hepatitis Type_____
High Blood Pressure

Stroke

Kidney Disease

Thyroid

Valve
Artifcial Joints
Tuberculosis

Diabetes Type______

Arthritis

Dizziness/Fainting Mitral Valve Prolapse

Asthma
Disease
Autism /
Aspergers

Liver Problems

Epilepsy/Seizures Mononucleosis

Ulcers

Venereal

Frequent Ear Infections Pacemaker

Bleeding Disorder Frequent Headaches

Other:____________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
__
_____________________________________________________________________________
Family Medical History
Father:
4

 Alive

Current Age:___________

Deceased
Age of
death/cause:____________________________________________
My fathers general health is:
Excellent

Good

Fair

Poor

Reason for poor

health:__________________________________________________________
Mother:
Alive

Current Age:___________

Deceased
Age of
death/cause:____________________________________________
My mothers general health is:
Excellent

Good

Fair

Poor

Reason for poor

health:__________________________________________________________
Siblings:
No Siblings
Sibling #1:
Alive

Current Age:___________

Deceased
Age of
death/cause:____________________________________________
My siblings general health is:
Excellent

Good

Fair

Poor

Reason for poor

health:__________________________________________________________
Sibling #2:
Alive
5

Current Age:___________

Deceased
Age of
death/cause:____________________________________________
My siblings general health is:
Excellent

Good

Fair

Poor

Reason for poor

health:__________________________________________________________
Sibling #3
Alive

Current Age:___________

Deceased
Age of
death/cause:____________________________________________
My siblings general health is:
Excellent

Good

Fair

Poor

Reason for poor

health:__________________________________________________________
Sibling #4:
Alive

Current Age:___________

Deceased
Age of
death/cause:____________________________________________
My siblings general health is:
Excellent

Good

Fair

Poor

Reason for poor

health:__________________________________________________________
Familial Diseases
Have you or your blood relatives had any of the following (include
grandparents, aunts, and uncles, but exclude cousins and relatives by
marriage)
Check those to which the answer is yes.
Heart attacks under age 50
Strokes under age 50
6

 High Blood Pressure

Elevated Cholesterol
Diabetes Type______
Asthma or hay fever
Congenital heart disease (existing at birth not hereditary)
Heart operations
Glaucoma
Obesity
Leukemia or cancer under age 60
Comments:_________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
___
_____________________________________________________________________________
Social History
Employer /
Occupation:__________________________________________________________
Occupational exposures: Fumes Dust
Particles

Solvents

Airborne

Noise
Alcohol: Never

Rarely Moderate

Daily

Quit

Daily

Quit

Drinks per day:____________/week

Type:_______________________________
Previous Quit Date:_____________________
Tobacco: Never

Rarely Moderate

Packs per day:______________ Previous Quit Date:________________

Cafeine: Never

Rarely Moderate

Daily

Amount per day:_____________

Type:_____________________________________
Use of Recreational Drugs: Never Rarely Moderate
7

Daily

Type:__________________________ Previous Quit

Date:_________
Exercise: Never

Rarely Moderate

Daily

Type:_________________________________________________________________
Do you have any pet? Yes

No

If Yes, what type of pet do you have?

______________________________
Are you sexually active? Yes No
Do you travel outside the US? Yes

No

Do you have any Advanced Directives? Yes

1.)

No

Do you have a Living Will? Yes

No

A living will allows you to document your wishes concerning

medical treatments at the end of life.
2.) Do you have a Medical Power of Attorney? Yes No
A medical power of attorney (or healthcare proxy) allows you to
appoint a person you trust as your healthcare agent (or surrogate decision
maker), who is authorized to make medical decisions on your behalf.
_____________________________________________________________________________
Pharmacy / Medications
Pharmacy Name:___________________________ Phone
#:____________________________
Address:____________________________________________________________________
__
City:___________________________________ State:________________
Zip:______________
Change of Pharmacy:
Date of Change:_______________
Pharmacy Name:___________________________ Phone
#:____________________________
8

Address:____________________________________________________________________
__
City:___________________________________ State:________________
Zip:______________
Date of Change:_______________
Pharmacy Name:___________________________ Phone
#:____________________________
Address:____________________________________________________________________
__
City:___________________________________ State:________________
Zip:______________
Date of Change:_______________
Pharmacy Name:___________________________ Phone
#:____________________________
Address:____________________________________________________________________
__
City:___________________________________ State:________________
Zip:______________
Date of Change:_______________
Pharmacy Name:___________________________ Phone
#:____________________________
Address:____________________________________________________________________
__
City:___________________________________ State:________________
Zip:______________
Date of Change:_______________
Pharmacy Name:___________________________ Phone
#:____________________________
Address:____________________________________________________________________
__
City:___________________________________ State:________________
Zip:______________
9

Date of Change:_______________
Pharmacy Name:___________________________ Phone
#:____________________________
Address:____________________________________________________________________
__
City:___________________________________ State:________________
Zip:______________
Date of Change:_______________
Pharmacy Name:___________________________ Phone
#:____________________________
Address:____________________________________________________________________
__
City:___________________________________ State:________________
Zip:______________
Date of Change:_______________
Pharmacy Name:___________________________ Phone
#:____________________________
Address:____________________________________________________________________
__
City:___________________________________ State:________________
Zip:______________
Date of Change:_______________
Pharmacy Name:___________________________ Phone
#:____________________________
Address:____________________________________________________________________
__
City:___________________________________ State:________________
Zip:______________
Date of Change:_______________
Pharmacy Name:___________________________ Phone
#:____________________________
10

Address:____________________________________________________________________
__
City:___________________________________ State:________________
Zip:______________
Date of Change:_______________
Pharmacy Name:___________________________ Phone
#:____________________________
Address:____________________________________________________________________
__
City:___________________________________ State:________________
Zip:______________

Medication List:
Please list all prescription, over the counter, vitamins and dietary
supplements.
MEDICATION

DOSE (Mg,Units,Drops)

REASON
1. __________________________
_______________________
2. __________________________
_______________________
3. __________________________
_______________________
4. __________________________
_______________________
5. __________________________
_______________________
6. __________________________
_______________________
7. __________________________
_______________________
8. __________________________
_______________________
11

__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________

9. __________________________ __________________
_______________________
10.
__________________________ __________________
_______________________
11.
__________________________ __________________
_______________________
12.
__________________________ __________________
_______________________
13.
__________________________ __________________
_______________________
14.
__________________________ __________________
_______________________
15.
__________________________ __________________
_______________________
16.
__________________________ __________________
_______________________
17.
__________________________ __________________
_______________________
18.
__________________________ __________________
_______________________
19.
__________________________ __________________
_______________________
20.
__________________________ __________________
_______________________
21.
__________________________ __________________
_______________________
22.
__________________________ __________________
_______________________
23.
__________________________ __________________
_______________________
24.
__________________________ __________________
_______________________
25.
__________________________ __________________
_______________________
26.
__________________________ __________________
_______________________
27.
__________________________ __________________
_______________________
28.
__________________________ __________________
_______________________
12

I authorize Amcare Family Practice PA to download and review my

medication history. When available, my prescriptions may be electronically
prescribed to the pharmacy listed above.
Patients Signature:_____________________________________
Date:___________________
Physicians Signature:___________________________________
Date:____________________
_____________________________________________________________________________
Statement of Financial Responsibility
I understand that I am responsible for the payment of this account and
hereby assume and guarantee prompt payment of all expenses incurred.
Notice of Non - Covered Services
I am aware that some services performed by Amcare Family Practice PA may
be considered non-covered by my insurance carrier or Medicare,
therefore, I will become fully responsible for these services.
Permission of Treatment
Permission is hereby granted for Amcare Family Practice PA physicians and
staf to render all medical information to the following. I give authorization
to discuss my protected health information with the following:
Name:__________________________ Relationship:___________________
DOB:___________
Name:__________________________ Relationship:___________________
DOB:___________
Name:__________________________ Relationship:___________________
DOB:___________
Name:__________________________ Relationship:___________________
DOB:___________
Name:__________________________ Relationship:___________________
DOB:___________
Name:__________________________ Relationship:___________________
DOB:___________
Notice of Privacy Practices
13

I acknowledge that I have been provided with the Practices Notice of

Privacy Practices that provides a description of Protected Health Information
uses and disclosures. I understand that I have the right to review the Notice
of Privacy Practices prior to signing this statement. I understand that
Amcare Family Practice PA reserves the right to change its Notice of Privacy
Practices that will be efective for health information the Practice already
has about me, as well as any they receive in the future. Amcare Family
Practice PA will post a current copy of Notice and I understand that I may
obtain a copy of the current Notice in efect upon request.
Patient Receipt of HIPAA Privacy Notice
Dear Patient,
Amare Family Practice PA is committed to maintaining the integrity of your
protected health information and complies with all applicable state and
federal regulations. The federal privacy regulations of the Health Insurance
Portability and Accountability Act (HIPAA) have taken efect April 14, 2003.
In support of our policy of complying with all applicable regulations, Amcare
Family Practice PA provides patients with the HIPAA Notice of Privacy Rights.
While not required in order to receive treatment at Amcare Family Practice
PA, we are obliged under federal regulations to ask that you sign an
acknowledgement of the HIPAA Privacy Notice being make available to you.
Thank you, Receipt of HIPAA Privacy Notice I acknowledge receipt of the
Notice of Privacy Rights with detailed information about how Amcare Family
Practice PA may use and disclose my protected health information. I
understand that Amcare Family Practice PA reserves the right to change the
privacy notice and that a copy of the revised notice will be made available
to me.
I have read all of the above and understand/agree to all provisions therein
regarding responsibility for payment, permission for treatment, and HIPAA
Notice of Privacy Practices.
Patients Printed
Name:__________________________________________________________
Patients Signature:____________________________________
Date:____________________

14

If Legal Guardian, Relationship to

Patient:___________________________________________
***Office Use Only: To be completed only when patient declines to sign
acknowledgement***
Check here is patient declined to sign acknowledgement
Staf Signature:_________________________________________
Date:___________________
*Refusal to sign acknowledgement does not prevent the patient from
continuing to be treated.

15