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Download patient intake form - Primary Care Acupuncture Center
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PATIENT INTAKE FORM - WC-NF-PI Dear Patient, Wholistic Health is an integrated approach to wellness that treats the whole person, not simply symptoms and disease. The information you provide for us in this Entrance Case History / Patient Intake form will assist us in planning your treatment protocol. In addition to this information, it would be helpful if you would bring in any medical records pertinent to your condition, such as blood test results, CAT scan, MRI, X-Rays or other reports The information you provide is confidential. Thank you for your cooperation. ENTRANCE CASE HISTORY Please write or print clearly Today’s date / □ Male □ Female / Last Name_______________________________First Name_______________________________Middle Initial__________ Date of Birth _______________________Age__________Social Security Number__________________________________ Address______________________________________________________________________________________________ City_________________________________________________________State__________________Zip_______________ Home Phone___________________________________Work or Cell Phone_______________________________________ Marital Status: □Single □Married □Separated □Divorced □Widowed □Domestic Partner Occupation_______________________________________________________Last grade completed___________________ eMail___________________________________________________ Ph # of Em cont:_______________________________ Emergency Contact / Relationship:________________________________________________________________________ IF UNDER THE AGE OF 18, PARENTS’ / GUARDIANS’ NAMES REQUESTED Mother’s Name____________________________________Father’s Name________________________________________ Guardian’s Name(s)______________________________________Relationship____________________________________ Emergency Contact______________________________________________________Phone_________________________ INSURANCE INFORMATION for WC, NF or PI fill in bolded areas Type of Claim: (Please circle one) WC NF PI Date of accident____________________________________ Insurance Company____________________________________________________Ins Co ph #_____________________ Insurance Co Address_________________________________________________________________________________ Claim # _____________________________________________ Policy or Carrier Case #___________________________ Rep name & phone # __________________________________________________________________________________ Attorney name & phone # ______________________________________________________________________________ Injuries case established for ______________________________________________________________________________ Eligibility & Benefits___________________________________________________________________________________ ____________________________________________________________________________________________________ Spoke to______________________________________ Verified by/date__________________________________________ How did you hear of our center? □ Referral by whom_______________________________ □ Advertisement which one______________________________ Please List Your Major Complaints and Diagnoses in Order of Importance / Severity: Date Problem Began 1.____________________________________________________________ ____/____/____ ______________________________________________________________ 2.____________________________________________________________ ____/____/____ ______________________________________________________________ 3._____________________________________________________________ ____/____/____ ______________________________________________________________ 4._____________________________________________________________ ____/____/____ ______________________________________________________________ 5._____________________________________________________________ ____/____/____ _______________________________________________________________ Please list all known allergies________________________________________________________ ________________________________________________________________________________ Please list all medications you are taking now____________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ Please list all supplements you are taking now____________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ All of the above information, to the best of my knowledge has been filled out correctly. Signature___________________________________________________ Date__________________
