Medical In-Take And History Form

Personal Information

Your Gender
MaleFemale

Person Responsible For Payment

If other than you

Medical History

Past Medical History - Please check all that apply

AnxietyArthritisArterial FibrillationBreast CancerColon CancerCOPDCoronary Artery DiseaseDepressionDiabetesRenal DiseaseGerd (Influx)Hearing LossHepatitisHigh Blood PressureHIV / AIDSHigh CholesterolLeukemiaLung CancerLymphomaProstate CancerRadiation TreatmentSeizuresStrokeHypothryroidHyperpthyroidCancerNone Apply

Medications

Social History - Please check all that apply

Cigarette Smoker
DailySome DaysFormer SmokerNever Smoked

Sexual Activity - Optional
Not sexually activeSexually Active
If sexually active
1 partnermore than 1 partnersame sex partner

Drug Use
Drug UseIV Drug Use

Alcohol Use
none1 drink per day2 drinks per day3 or more drinks per day

Signature

I AUTHORIZE THE RELEASE OF MEDICAL INFORMATION TO MY PRIMARY CARE OR REFERRING PHYSICIAN, TO CONSULTANTS IF NEEDED AND AS NECESSARY TO PROCESS INSURANCE CLAIMS, INSURANCE APPLICATIONS, AND PRESCRIPTIONS. I ALSO AUTHORIZE PAYMENTS OF MEDICAL BENEFITS TO PALMS ACUPUNCTURE AND WELLNESS.

PAYMENT IS REQUIRED FOR ALL SERVICES AT THE TIME THEY ARE RENDERED. I HAVE HAD A CHANCE TO READ OVER THE FINANCIAL RESPONSIBILITY FORM.

Signature of patient or responsible party

If you are the responsible party signing for the patient please indicate your relationship to the patient

Please prove you are human by selecting the Cup.