Date:____________________

LastName:________________________FirstName:_________________________MI:______
SocialSecurity#(SSI):_________________DOB:______________Nickname:______________
Address:_________________________________________________APT#:_______________
City:______________________________State:_______________Zip:___________________
HomePhone#:__________________________WorkPhone#:__________________________
CellPhone#:_________________________
PreferredContactMethod:__Home__Work__Cell
Iauthorizevoicemailmessages:__Yes__No
AlternateAddress:_________________________________________APT#:_______________
City:______________________________State:_______________Zip:___________________
Ifalternateaddressisseasonal,pleaseindicatethedatesthisaddressistobeused:____________________________
Gender:__Female__Male
Ethnicity:___________________Race:_________________(Asian,Black,Hispanic,White,etc.)
Insurance
PrimaryInsurance:___________________________MemberID#:_______________________
InsuredName:______________________________________DOB:______________________
InsuredSS#:________________________InsuredEmployer:____________________________
EmployerAddress:______________________________________________________________
PlanType:__HMO__PPO__OpenAccessPCPName:_____________________________

InsuranceContinued
SecondaryInsurance:_________________________MemberID#:_______________________
InsuredName:______________________________________DOB:______________________
InsuredSS#:________________________InsuredEmployer:____________________________
EmployerAddress:______________________________________________________________
1

PlanType:__HMO__PPO__OpenAccessPCPName:_____________________________
_____________________________________________________________________________
EmergencyContact
EmergencyContact:_____________________________________________________________
Relationship:___________________________Phone#:________________________________
ParentInformation:Pleasebeadvisedthatminorchildren(under18)willnotbetreatedwithoutalegalguardian
present.Legalguardianotherthanparentmustprovideproofofguardianship.Pleasesignbelow:
ParentsPrintedName:_______________________________Relationship:________________
ParentsSignature:___________________________________Date:______________________
_____________________________________________________________________________
MedicalHistory
Whatareyoubeingseenfortoday?
_______________________________________________
_____________________________________________________________________________
Surgeries/Accidents/Hospitalizations:
ReasonDates
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Allergies
:Pleaselistallallergiesbelowandindicatethetypeofreaction.
Medication/Reaction:__________________________________________________________
Food/Reaction:_______________________________________________________________
Latex(Othermaterials)/Reaction:_________________________________________________
AllPatients:Doyouhave,orhaveeverhadanyofthefollowing?(Checkallthatapply)
__NONE
__AcidReflux

__Bulimia

__HearingProblems

__PsychiatricTreatment

__ADHD

__Cancer/Malignancy

__HeartAttack

__Radiation/Chemo

__AIDS/HIV

__CerebralPalsy

__HeartDisease

__RespiratoryDisease

__Anemia

__ChemicalDependency

__HeartMurmur

__RheumaticFever

__Anorexia

__ChickenPox

__HepatitisType_____

__SinusProblems

__Anxiety

__Convulsions

__HighBloodPressure

__Stroke

__ArtificialHeart

__Depression

__KidneyDisease

__ThyroidDisease

__ArtificialJoints

__DiabetesType______

__LiverProblems

__Tuberculosis

__Arthritis

__Dizziness/Fainting

__MitralValveProlapse

__Asthma

__Epilepsy/Seizures

__Mononucleosis

__Autism/

__FrequentEarInfections

__Pacemaker

Aspergers

__BleedingDisorder

__FrequentHeadaches

Valve

__Ulcers
__VenerealDisease

__Other:_________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
______
_____________________________________________________________________________
FamilyMedicalHistory
Father:
__Alive
__Deceased

CurrentAge:___________

Ageofdeath/cause:____________________________________________

Myfathersgeneralhealthis:
__Excellent

__Good

__Fair

__Poor

Reasonforpoorhealth:__________________________________________________________
Mother:
__Alive
__Deceased

CurrentAge:___________

Ageofdeath/cause:____________________________________________

Mymothersgeneralhealthis:
__Excellent

__Good

__Fair

__Poor

Reasonforpoorhealth:__________________________________________________________
Siblings:
__NoSiblings
Sibling#1:
__Alive
__Deceased
3

CurrentAge:___________

Ageofdeath/cause:____________________________________________

Mysiblingsgeneralhealthis:
__Excellent

__Good

__Fair

__Poor

Reasonforpoorhealth:__________________________________________________________

Sibling#2:
__Alive
__Deceased

CurrentAge:___________

Ageofdeath/cause:____________________________________________

Mysiblingsgeneralhealthis:
__Excellent

__Good

__Fair

__Poor

Reasonforpoorhealth:__________________________________________________________

Sibling#3
__Alive
__Deceased

CurrentAge:___________

Ageofdeath/cause:____________________________________________

Mysiblingsgeneralhealthis:
__Excellent

__Good

__Fair

__Poor

Reasonforpoorhealth:__________________________________________________________
Sibling#4:
__Alive
__Deceased

CurrentAge:___________

Ageofdeath/cause:____________________________________________

Mysiblingsgeneralhealthis:
__Excellent

__Good

__Fair

__Poor

Reasonforpoorhealth:__________________________________________________________
FamilialDiseases
Haveyouoryourbloodrelativeshadanyofthefollowing(includegrandparents,aunts,anduncles,butexclude
cousinsandrelativesbymarriage)
Checkthosetowhichtheanswerisyes.
__Heartattacksunderage50
__Strokesunderage50
__HighBloodPressure
__ElevatedCholesterol
__DiabetesType______
4

__Asthmaorhayfever
__Congenitalheartdisease(existingatbirthnothereditary)
__Heartoperations
__Glaucoma
__Obesity
__Leukemiaorcancerunderage60
Comments:______________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
_______
_____________________________________________________________________________
SocialHistory
Employer/Occupation:__________________________________________________________
Occupationalexposures:__Fumes

__Dust

__Solvents

__AirborneParticles

__Noise
Alcohol:__Never

__Rarely

__Moderate

__Daily

__Quit

Drinksperday:____________/week Type:_______________________________
PreviousQuitDate:_____________________
Tobacco:__Never

__Rarely

__Moderate

__Daily

__Quit

Packsperday:______________PreviousQuitDate:________________
Caffeine:__Never

__Rarely

__Moderate

__Daily

Amountperday:_____________Type:_____________________________________
UseofRecreationalDrugs:__Never

__Rarely

__Moderate

__Daily

Type:__________________________PreviousQuitDate:_________
Exercise: Never

__Rarely

__Moderate

__Daily

Type:_________________________________________________________________
Doyouhaveanypet?__Yes

__No

IfYes,whattypeofpetdoyouhave?______________________________
Areyousexuallyactive?__Yes __No
DoyoutraveloutsidetheUS?__Yes

__No

DoyouhaveanyAdvancedDirectives?__Yes__No
1.) DoyouhaveaLivingWill?__Yes__No
Alivingwillallowsyoutodocumentyourwishesconcerningmedicaltreatmentsattheendoflife.
5

2.)DoyouhaveaMedicalPowerofAttorney?__Yes

__No

Amedicalpowerofattorney(orhealthcareproxy)allowsyoutoappointapersonyoutrustasyour
healthcareagent(orsurrogatedecisionmaker),whoisauthorizedtomakemedicaldecisionsonyourbehalf.
________________________________________________________________________________________________
__
Pharmacy/Medications
PharmacyName:__________________________________________Phone#:____________________________
Address:____________________________________________________________________________________
City:________________________________________State:______________________Zip:_________________
ChangeofPharmacy:
DateofChange:_______________
PharmacyName:_________________________________________Phone#:____________________________
Address:_____________________________________________________________________________________
City:________________________________________State:______________________Zip:_________________
DateofChange:_______________
PharmacyName:_________________________________________Phone#:____________________________
Address:_____________________________________________________________________________________
City:________________________________________State:______________________Zip:_________________
DateofChange:_______________
PharmacyName:_________________________________________Phone#:____________________________
Address:_____________________________________________________________________________________
City:________________________________________State:______________________Zip:_________________
DateofChange:_______________
PharmacyName:_________________________________________Phone#:____________________________
Address:_____________________________________________________________________________________
City:________________________________________State:______________________Zip:_________________
DateofChange:_______________
PharmacyName:_________________________________________Phone#:____________________________
Address:_____________________________________________________________________________________
City:________________________________________State:______________________Zip:_________________
DateofChange:_______________
PharmacyName:_________________________________________Phone#:____________________________

Address:_____________________________________________________________________________________
City:________________________________________State:______________________Zip:_________________

MedicationList:
Pleaselistallprescription,overthecounter,vitaminsanddietarysupplements.
MEDICATIONDOSE(Mg,Units,Drops)REASON
1.
2.
3.
4.
5.
6.
7.
8.
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28.

___________________________________________________________________
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___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

IauthorizeAmcareFamilyPracticePAtodownloadandreviewmymedicationhistory.Whenavailable,my
prescriptionsmaybeelectronicallyprescribedtothepharmacylistedabove.
PatientsSignature:_____________________________________Date:___________________
PhysiciansSignature:___________________________________Date:____________________
_____________________________________________________________________________
StatementofFinancialResponsibility
IunderstandthatIamresponsibleforthepaymentofthisaccountandherebyassumeandguaranteeprompt
paymentofallexpensesincurred.

NoticeofNonCoveredServices
IamawarethatsomeservicesperformedbyAmcareFamilyPracticePAmaybeconsiderednoncoveredbymy
insurancecarrierorMedicare,therefore,Iwillbecomefullyresponsiblefortheseservices.
PermissionofTreatment
PermissionisherebygrantedforAmcareFamilyPracticePAphysiciansandstafftorenderallmedicalinformationto
thefollowing.Igiveauthorizationtodiscussmyprotectedhealthinformationwiththefollowing:
Name:__________________________Relationship:___________________DOB:___________
Name:__________________________Relationship:___________________DOB:___________
Name:__________________________Relationship:___________________DOB:___________
Name:__________________________Relationship:___________________DOB:___________
Name:__________________________Relationship:___________________DOB:___________
Name:__________________________Relationship:___________________DOB:___________
NoticeofPrivacyPractices
IacknowledgethatIhavebeenprovidedwiththePracticesNoticeofPrivacyPracticesthatprovidesadescriptionof
ProtectedHealthInformationusesanddisclosures.IunderstandthatIhavetherighttoreviewtheNoticeofPrivacy
Practicespriortosigningthisstatement.IunderstandthatAmcareFamilyPracticePAreservestherighttochangeits
NoticeofPrivacyPracticesthatwillbeeffectiveforhealthinformationthePracticealreadyhasaboutme,aswellas
anytheyreceiveinthefuture.AmcareFamilyPracticePAwillpostacurrentcopyofNoticeandIunderstandthatI
mayobtainacopyofthecurrentNoticeineffectuponrequest.
PatientReceiptofHIPAAPrivacyNotice
DearPatient,
AmareFamilyPracticePAiscommittedtomaintainingtheintegrityofyourprotectedhealthinformationand
complieswithallapplicablestateandfederalregulations.ThefederalprivacyregulationsoftheHealthInsurance
PortabilityandAccountabilityAct(HIPAA)havetakeneffectApril14,2003.Insupportofourpolicyofcomplyingwith
allapplicableregulations,AmcareFamilyPracticePAprovidespatientswiththeHIPAANoticeofPrivacyRights.While
notrequiredinordertoreceivetreatmentatAmcareFamilyPracticePA,weareobligedunderfederalregulationsto
askthatyousignanacknowledgementoftheHIPAAPrivacyNoticebeingmakeavailabletoyou.Thankyou,Receipt
ofHIPAAPrivacyNoticeIacknowledgereceiptoftheNoticeofPrivacyRightswithdetailedinformationabouthow
AmcareFamilyPracticePAmayuseanddisclosemyprotectedhealthinformation.IunderstandthatAmcareFamily
PracticePAreservestherighttochangetheprivacynoticeandthatacopyoftherevisednoticewillbemadeavailable
tome.

Ihavereadalloftheaboveandunderstand/agreetoallprovisionsthereinregardingresponsibilityforpayment,
permissionfortreatment,andHIPAANoticeofPrivacyPractices.

PatientsPrintedName:__________________________________________________________
PatientsSignature:____________________________________Date:____________________
IfLegalGuardian,RelationshiptoPatient:___________________________________________
8

***OfficeUseOnly:Tobecompletedonlywhenpatientdeclinestosignacknowledgement***
__Checkhereispatient
declined

tosignacknowledgement
StaffSignature:_________________________________________Date:___________________
*Refusaltosignacknowledgementdoesnotpreventthepatientfromcontinuingtobetreated.