Patient Admittance Form

Patient Admittance Form
Title: Mr.Mrs.MsMiss
Full Name:Date:
Address 1:
Address 2:
City:
State:	Zip:
Phone (home): Phone (work): Phone (cell):
Date of Birth:Age:Sex:MaleFemale
Spouse's Name:		Date Of Birth:
Employment Status: EmployedFull-Time StudentPart-Time StudentOther
Email Address:
Social Security #
Marital Status: SingleMarriedOther
Is it okay to call you at work?YesNo
Who can we thank for referring you to our office?

Spouse Data

Is your spouse a patient in this office? YesNo

Full Name:

Home Phone:

Work Phone:

Employer Data

Employer:

Address 1:

Address 2:

City:

State:

Zip:

Emergency Contact

Name:

Phone:

Family Physician

Name: Practice Name:

Phone:

Treatment Authorization

I hereby authorize this office and its staff and doctors to examine and treat my condition as the doctors deem appropriate and I give authority for these procedures to be performed. I clearly understand and agree that all services rendered to me are charged directly to me and that I am responsible for payment of services by this office and all outside laboratory or radiology services performed on my behalf. Should collection of past due amount become necessary, I will become responsible for all charges, fees and attorney fees. I (we) hereby authorize the doctor to release all information necessary to secure payment of benefits. I authorize the use of this signature on all insurance submissions.

Name:

Consent to Treat a Minor

I (we) being the parents, guardian or custodian of the minor being , Age , do hereby authorize, request, and direct this office, its doctors and staff to perform examinations, diagnostic X-rays, laboratory tests, and any treatment that in their judgment is deemed advisable or is required while said minor child is under care of this office’s doctors and staff until legal age. All charges for services and care given to said minor child will be charged directly to me (us) and I (we) will be personally responsible for payment of them. I(we) authorize doctor to release all information necessary to secure payment of benefits. I (we) authorize the use of this signature on all insurance submissions.

Name:

Acknowledgement of Receipt

As required by the Privacy Regulation, I hereby acknowledge that I have received a current copy of the Notice of
Privacy Practices of the Dynamic Health Center.

I am aware that the Dynamic Health Center has included a provision that it reserves the right to change the terms of
this notice and to make the new notice provisions effective for all Protected Health Information that it maintains.

Name:

If signed by a representative of the patient:

Representative's Name:

Relationship:

(Office Use Only)

Authorized Facility Signature: Date:

Good faith effort to obtain receipt (describe):

Is it ok to call you at work?

Yes or No:

Who can we thank for referring yoou to our office?

Family Member	Attorney	Internet Web site	Health Class
Friend	Yellow Pages	Billboard	Brochure
Physician	Newspaper Ad	TV Commercial	Direct Mail Ad
Employer	Sign on building	Radio	Other

If you selected 'Yellow Pages' please indicated which Yellow Pages ( Yellow Pages or Yellow Book ):

If you selected 'family member', 'friend', or 'physician' please enter their name:

If you selected 'other' please describe:

Medical Conditions:

Arthritis Cancer Diabetes Heart Disease
Hypertension Psychiatric Illness Skin Disorder Stroke

Surgeries:

Appendectomy Cardiovascular procedure Cervical disc procedure Hysterectomy
Joint replacement Laminectomies Radical prostatectomy Transuretheral prostate surgery

Allergies:

Eggs Fish and Shellfish Milk or Lactose Peanut
Soy Sulfites Wheat/Gluten

Social History:

Caffeine used occasionally Caffeine used often
Chew tobacco occasionally Chew tobacco often
Drink alcohol occasionally Drink alcohol often
Exercise not at all Exercise occasionally Exercise often
Experience stress occasionally Experience stress often
Smoke 1 pack or less per day Smoke more than 1 pack a day
Wear seat belts always Wear seat belts never Wear seatbelts usually

Family History:

Arthritis (parent) Arthritis (sibling) Cancer (parent) Cancer (sibling) Cholesterol (parent) Cholesterol (sibling) Diabetes (parent) Diabetes (sibling) Heart problems (parent) Heart problems (sibling) High blood pressure (parent) High blood pressure (sibling) Psychiatric (parent) Psychiatric (sibling) Stroke (parent) Stroke (sibling) Thyroid (parent) Thyroid (sibling)

Substance Use:

Alcohol (past) Alcohol (present) Amphetamines (past) Amphetamines (present) Barbiturates (past) Barbiturates (present) Cocaine (past) Cocaine (present) Crystal Meth (past) Crystal Meth (present) Heroine (past) Heroine (Present) Marijuana (past) Marijuana (present)

Male Children:

Under 6 years Under 10 years Under 19 years

Female Children:

Under 6 years Under 10 years Under 19 years

Occupational Activities:

Administration Business owner Clerical/secretarial Computer user Construction Daycare/childcare Executive/legal Food service industry Health care Heavy equipment operator Heavy manual labor Home services Household Light manual labor Manufacturing Medium manual labor

Review of Systems:
Cardiovascular 'No' for ALL	Respiratory 'No' for ALL	Allergic/Immunologic 'No' for ALL
Poor Circulation	Asthma	Hives
High Blood Pressure	Tuberculosis	Immune Disorder
Aortic Aneurism	Shortness of Breath	HIV/AIDS
Heart Disease	Emphysema	Allergy Shots
Heart Attack	Cold/Flu	Cortisone Use
Chest Pain	Cough/Wheezing
High Cholesterol
Pace Maker
Jaw Pain
Irregular Heartbeat
Swelling of Legs

Genitourinary 'No' for ALL	Ears/Nose/Throat 'No' for ALL	Gastrointestinal 'No' for ALL
Kidney Disease	Dizziness	Gallbladder Problems
Lower Side Pain	Hearing Loss	Bowel Problems
Burning Urination	Sinus Infection	Constipation
Frequent Urination	Nosebleed	Liver Problems
Blood in Urine	Sore Throat	Ulcers
Kidney Stone	Difficulty Swallowing	Diarrhea
	Bleeding Gums	Nausea/Vomiting
		Bloody Stools
		Poor Appetite

Hematologic/Lymphatic 'No' for ALL	Integumentary 'No' for ALL	Musculoskeletal 'No' for ALL
Hepatitis	Skin Ulcers	Gout
Blood Cots	Skin Disease	Arthritis
Cancer	Eczema	Joint Stiffness
Easy Bruising	Psoriasis	Muscle Weakness
Fevers/Chills/Sweats	Rashes	Osteoporosis
		Broken Bones
		Joints Replaced

Neurologic 'No' for ALL	Eyes 'No' for ALL	Endocrine 'No' for ALL
Stroke	Glaucoma	Thyroid Disease
Seizures	Double Vision	Diabetes
Head Injury	Blurred Vision	Hair Loss
Brain Aneurysm		Menopausal
Numbness		Menstrual Problems
Severe Headaches
Pinched Nerves
Parkinson's Disease
Carpal Tunnel
Spinning/Balance

Psychiatric 'No' for ALL	Constitutional 'No' for ALL
Depression	Weight Loss/Gain
Anxiety Disorder	Energy Level Problem
Unusual Stress	Difficulty Sleeping

For verification purposes, please type in the numbers and letters that you see below then press the Send Request button