Patient Intake Form - Austin Holistic Health

Confidential Patient Intake Form

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Name

First

Last

Date

Full Address

Phone

Work Phone

Referred by

Age

Birth Date

Sex

Male
Female

Marital Status

Single
Married
Divorced
Widowed

Spouse's Name

Spouse's Number

Number of Children

Occupation

Employer & Address

Emergency Contact

Emergency Contact Number

Date of Last Physical Exam

Name of Doctor

Where Was Your Last Physical Exam?

Reported Findings

Surgeries, Hospitalizations, Serious Illnesses (List Year in Brackets):

Fractures, Dislocations, Major Dental Work (List Year in Brackets):

Conditions You Have Had:

If Other, please explain:

Purpose of This Appointment

Other Doctors Seen For This Condition:

Exam? Work Number

Have You Been Treated For Any Other Condition in The Past Year? Yes / No (If So, Describe):

Medications / Drugs You Are Taking (state reason in brackets following drug):

Remarks / Additional Information:

Payment is expected at the time of visit. You will be expected to bring payment information or the form of payment required upon your visit. By submitting this form, you agree to the following.

PATIENT AGREEMENT: I understand and agree that health and accident insurance policies are an arrangement between my insurance carrier and myself. Furthermore, I understand that I am personally responsible for payment, both for services when rendered and for missed appointments if I fail to give twenty-four hour advance notice of cancellation.

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