Patient Information Form
|Referred by: __________________________________
Name: ______________________________________ DOB: __________ Age: _________
Home #:_______________________ Work #:____________________ Cell #:______________________
E-mail:___________________________ SS#: _________________ Driver's Lic.:____________________
Spouse: ___________________________________ Tel: ____________________________
Guardian (if applicable):__________________________ Tel: ___________________________
Person to contact in case of emergency (relationship):_________________________________________
Occupation: _____________________ Employer: ____________________ Tel: ____________________
Primary Physician: _______________________________ Tel: ___________________________
Insurance Company: ___________________________________________________________________
Insurance Identification Number: __________________________________________________________
Name of Insured: ______________________________________________________________________
Group Policy Number: __________________________________________________________________
Chief Complaint (CC):______________________________________________
History of CC (what, when, why, where, how, time, alleviated by, aggravated by):____________________
Additional Complaints (head, neck, chest, breasts, arms, hands, abdomen, pelvis,
genitalia, legs, feet, cough, hemorrhoids, constipation, congestion, pain, etc):
Medications-including herbs, supplements, remedies: _________________________________________
Previous care taken for this CC:___________________________________________________________
Past Medical History:
__measles __hypertension __rheumatic fever __headaches __cancer
__mumps __heart disease __scarlet fever __migraines __depression
__rubella __kidney disease __tuberculosis __Candida __ulcers
__hives __UTI __immune disorder __glaucoma __hepatitis
__eczema __liver disease __thyroid disease __heart murmurs
__anemia __bleeding disorder __gallbladder dis. __blood clots __insomnia
__asthma __pneumonia __Epstein Barr __edema __diabetes
__stroke __seizure __venereal disease __other (explain)
Past Surgical History:
__tonsils __adenoids __appendix __uterus __tooth extraction
__ovaries __eye __neck __chest __skin excision
__abdomen __gallbladder __bowel __breast __circumcision
__fractures __stitches __bunions __scars __other (explain)
Accidents/trauma/injuries-even as a child-(Motor vehicle, sporting, pedestrian):______________________
Family History (paternal, maternal, siblings):
__asthma __diabetes __glaucoma __hypertension __cancer
__depression __alcoholism __psychological __kidney disorder
__immune disorder __arthritis __other (explain)
Travel History (where, when, how long, illness? frequency):______________________________________
Eating habits/diet: _____________________________________________________________________
Tobacco use-present and past (how much, how long, how often):_______________________________
Alcohol use-present and past (how much, how long, how often):________________________________
Caffeine use-present and past (How much, how long, how often):_______________________________
Sleeping habits: _______________________________________________________________________
Marital status: ________________________________________________________________________
Children (natural, adopted, mixed family):__________________________________________________
Relatives living in the household: _________________________________________________________
Job related activities: __________________________________________________________________
Pregnancy: Number: _______ Living: _______ Menses/ Age at onset: _______
Duration: ______Complications: _______________________
Date of last menstrual period: ________
Medications: ________________________ Associations: _______________________
Delivery (surgical, natural, induced):_______ Age of menopause: _________________
Medications: _________________________ Associations: _____________________
Last Pap (and results):______________________
Last mammogram (and results):_______________
Contact lens/glasses: __________________________ Last eye exam: ____________________________
Laboratory and radiographic studies performed: _____________________________________________
I have read and agree to the following:
Treatment is by appointment only. Your appointment time is reserved for you. If you must cancel or
change an appointment, please notify us as soon as possible so that the time may be used to help
another. You will be responsible for a cancellation charge of $95.00 for an appointment not cancelled
24 hours in advance.
Patients must be under the care of a physician for any pre-existing health problems and are responsible
for keeping this office informed of the current name, address, and telephone number of such physician.
Any criticism or complaint about the office, its practitioners, or its practices are welcomed.
Signature: _________________________________ Date: ________________
I hereby assume full financial responsibility for and agree (regardless of my insurance status) that I am
ultimately responsible for the full payment on my and /or my dependant's accounts for all charges for
professional services rendered and medical supplies received.
Full payment is due at the time that services are rendered.
I understand that a medical insurance contract is a contract either between an individual and the
insurance company or between the employer for whom the individual works or is affiliated and the
insurance carrier. This contract does not involve a contract between the physician and the
insurance carrier. Such a contract has been known to interfere with the doctor-patient relationship.
The office is therefore unable to accept payment from insurance programs. The patient will receive
a copy of the "super bill" which has all of the necessary information for insurance processing. This
is to be either submitted or transcribed on the individual insurance company forms. If further
assistance is needed in completing the insurance forms, please contact this office.
Whether your insurance company pays in full, a portion, or no part of your medical bills is a matter
between you and your insurance carrier.
This office is not responsible for the collection of your insurance claim or for negotiating a settlement
on a disputed claim, but will help out in the form of letters and explanations when necessary.
I agree that I am responsible for the reasonable fees that will be charged for any and all services and
fees connected with investigation, litigation or collection.
I agree that I am responsible for customary bank fees charged for returned checks or for insufficient
I permit a copy of this authorization and agreement to be used in place of the original.
Signature: ______________________________ Date: ___________
REPORTS AND FORMS:
I authorize the release of medical information required by my insurance carrier or its designated
review agent in order to process any insurance claim for benefits. This authorization may be revoked
or changed by me in writing at any time. There may be a fee of charged for dictation, filing of long
reports, or excessive photocopying. This fee will be proportionate to the amount of time charged for
an office visit. I am responsible for this fee should it apply.
A copy of this authorization will be deemed as valid as the original authorization.
Signature: _____________________________ Date: _______________
New regulations for HIPPA are out. This office, though exempt because there are no third parties in
We make every effort to ensure that the privacy of you medical record is maintained. To help us do
this, we ask that:
1. All requests for medical records be made in writing. For your convenience a standard medical
release form is available.
2. Medical record be sent by mail, rather than fax, to a designated person.
3. You not discuss sensitive medical information with non-medical personnel, leave such information
on the answering machine, or send such information via email.
For that same reason, Dr. Howard will not leave information on a message machine nor will she
respond to medical questions via email.