Date: ____________________

Last Name:________________________ First Name:_________________________MI:______

Social Security # (SSI):_________________ DOB:______________ Nickname:______________
Address:_________________________________________________ APT#:_______________
City:______________________________ State:_______________ Zip:___________________
Home Phone #:__________________________ Work Phone#:__________________________
Cell Phone#:_________________________
Preferred Contact Method: Home

Work

I authorize voicemail messages: Yes

Cell

No

Alternate Address:_________________________________________ APT#:_______________

City:______________________________ State:_______________ Zip:___________________
If alternate address is seasonal, please indicate the dates this address is to be
used:____________________________
Gender: Female

Male

Ethnicity:___________________ Race:_________________(Asian, Black, Hispanic, White, etc.)

Insurance
Primary Insurance:___________________________ Member ID #:_______________________
Insured Name:______________________________________ DOB:______________________
Insured SS#:________________________ Insured Employer:____________________________
Employer Address:______________________________________________________________
Plan Type: HMO

PPO

Open Access PCP Name:_____________________________

Insurance Continued
Secondary Insurance:_________________________ Member ID #:_______________________
Insured Name:______________________________________ DOB:______________________
Insured SS#:________________________ Insured Employer:____________________________
Employer Address:______________________________________________________________
1

Plan Type: HMO

PPO

Open Access PCP Name:_____________________________

_____________________________________________________________________________
Emergency Contact
Emergency Contact:_____________________________________________________________
Relationship:___________________________ Phone#:________________________________
Parent Information: Please be advised that minor children (under 18) will not be treated without a
legal guardian present. Legal guardian other than parent must provide proof of guardianship.
Please sign below:
Parents Printed Name:_______________________________ Relationship:________________
Parents Signature:___________________________________ Date:______________________
_____________________________________________________________________________
Medical History
What are you being seen for today?_______________________________________________
_____________________________________________________________________________
Surgeries / Accidents / Hospitalizations:
Reason

Dates

________________________________________________

________________________

________________________________________________

________________________

________________________________________________

________________________

________________________________________________

________________________

________________________________________________

________________________

________________________________________________

________________________

________________________________________________

________________________

Allergies: Please list all allergies below and indicate the type of reaction.
Medication / Reaction:__________________________________________________________
Food / Reaction:_______________________________________________________________
Latex (Other materials) / Reaction:_________________________________________________
All Patients: Do you have, or have ever had any of the following? (Check all that
apply)
NONE
Acid Refux

Bulimia

Hearing Problems

Psychiatric Treatment

ADHD

Cancer/Malignancy

Heart Attack

Radiation/Chemo

AIDS/HIV

Cerebral Palsy

Heart Disease

Respiratory Disease

 Anemia

Chemical Dependency Heart Murmur

Rheumatic Fever

Anorexia

Chicken Pox

Hepatitis Type_____

Sinus Problems

Anxiety

Convulsions

High Blood Pressure

Stroke

Artifcial Heart

Depression

Kidney Disease

Thyroid Disease

Artifcial Joints

Diabetes Type______

Liver Problems

Tuberculosis

Arthritis

Dizziness/Fainting

Mitral Valve Prolapse

Ulcers

Asthma

Epilepsy/Seizures

Mononucleosis

Venereal Disease

Autism /

Frequent Ear Infections Pacemaker

Valve

Aspergers

Bleeding Disorder

Frequent Headaches

Other:_________________________________________________________________________________________
__________________________________________________________________________________________________
_____________________________________
_____________________________________________________________________________
Family Medical History
Father:
Alive

Current Age:___________

Deceased

Age of death/cause:____________________________________________

My fathers general health is:

Excellent

Good

Fair

Poor

Reason for poor health:__________________________________________________________

Mother:
Alive

Current Age:___________

Deceased

Age of death/cause:____________________________________________

My mothers general health is:

Excellent

Good

Fair

Poor

Reason for poor health:__________________________________________________________

Siblings:
No Siblings
Sibling #1:
Alive
Deceased
3

Current Age:___________
Age of death/cause:____________________________________________

My siblings general health is:

Excellent

Good

Fair

Poor

Reason for poor health:__________________________________________________________

Sibling #2:
Alive

Current Age:___________

Deceased

Age of death/cause:____________________________________________

My siblings general health is:

Excellent

Good

Fair

Poor

Reason for poor health:__________________________________________________________

Sibling #3
Alive

Current Age:___________

Deceased

Age of death/cause:____________________________________________

My siblings general health is:

Excellent

Good

Fair

Poor

Reason for poor health:__________________________________________________________

Sibling #4:
Alive

Current Age:___________

Deceased

Age of death/cause:____________________________________________

My siblings general health is:

Excellent

Good

Fair

Poor

Reason for poor health:__________________________________________________________

Familial Diseases
Have you or your blood relatives had any of the following (include grandparents, aunts, and
uncles, but exclude cousins and relatives by marriage)
Check those to which the answer is yes.
Heart attacks under age 50
Strokes under age 50
High Blood Pressure
Elevated Cholesterol
Diabetes Type______
Asthma or hay fever
4

 Congenital heart disease (existing at birth not hereditary)

Heart operations
Glaucoma
Obesity
Leukemia or cancer under age 60
Comments:______________________________________________________________________________________
__________________________________________________________________________________________________
______________________________________
_____________________________________________________________________________
Social History
Employer / Occupation:__________________________________________________________
Occupational exposures: Fumes

Dust

Solvents Airborne Particles

Noise
Alcohol: Never

Rarely

Moderate

Drinks per day:____________/week

Daily

Quit

Type:_______________________________

Previous Quit Date:_____________________

Tobacco: Never Rarely

Moderate

Daily

Quit

Packs per day:______________ Previous Quit Date:________________

Cafeine: Never Rarely

Moderate Daily

Amount per day:_____________ Type:_____________________________________

Use of Recreational Drugs: Never

Rarely

Moderate

Daily

Type:__________________________ Previous Quit Date:_________

Exercise: Never Rarely

Moderate

Daily

Type:_________________________________________________________________
Do you have any pet? Yes

No

If Yes, what type of pet do you have?______________________________

Are you sexually active? Yes No
Do you travel outside the US? Yes

No

Do you have any Advanced Directives? Yes

1.) Do you have a Living Will? Yes

No
No

A living will allows you to document your wishes concerning medical treatments at
the end of life.
2.) Do you have a Medical Power of Attorney? Yes
5

No

A medical power of attorney (or healthcare proxy) allows you to appoint a person
you trust as your healthcare agent (or surrogate decision maker), who is authorized to make
medical decisions on your behalf.
_____________________________________________________________________________
Pharmacy / Medications
Pharmacy Name:___________________________ Phone #:____________________________
Address:______________________________________________________________________
City:___________________________________ State:________________ Zip:______________
Change of Pharmacy:
Date of Change:_______________
Pharmacy Name:___________________________ Phone #:____________________________
Address:______________________________________________________________________
City:___________________________________ State:________________ Zip:______________
Date of Change:_______________
Pharmacy Name:___________________________ Phone #:____________________________
Address:______________________________________________________________________
City:___________________________________ State:________________ Zip:______________
Date of Change:_______________
Pharmacy Name:___________________________ Phone #:____________________________
Address:______________________________________________________________________
City:___________________________________ State:________________ Zip:______________
Date of Change:_______________
Pharmacy Name:___________________________ Phone #:____________________________
Address:______________________________________________________________________
City:___________________________________ State:________________ Zip:______________
Date of Change:_______________
Pharmacy Name:___________________________ Phone #:____________________________
Address:______________________________________________________________________
City:___________________________________ State:________________ Zip:______________

Date of Change:_______________
Pharmacy Name:___________________________ Phone #:____________________________
Address:______________________________________________________________________
6

City:___________________________________ State:________________ Zip:______________

Date of Change:_______________
Pharmacy Name:___________________________ Phone #:____________________________
Address:______________________________________________________________________
City:___________________________________ State:________________ Zip:______________
Date of Change:_______________
Pharmacy Name:___________________________ Phone #:____________________________
Address:______________________________________________________________________
City:___________________________________ State:________________ Zip:______________
Date of Change:_______________
Pharmacy Name:___________________________ Phone #:____________________________
Address:______________________________________________________________________
City:___________________________________ State:________________ Zip:______________
Date of Change:_______________
Pharmacy Name:___________________________ Phone #:____________________________
Address:______________________________________________________________________
City:___________________________________ State:________________ Zip:______________
Date of Change:_______________
Pharmacy Name:___________________________ Phone #:____________________________
Address:______________________________________________________________________
City:___________________________________ State:________________ Zip:______________

Medication List:
Please list all prescription, over the counter, vitamins and dietary supplements.
MEDICATION
1.
2.
3.
4.
5.
6.
7.
8.
9.
7

__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________

DOSE (Mg,Units,Drops)
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________

_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________

REASON

10.__________________________
11.__________________________
12.__________________________
13.__________________________
14.__________________________
15.__________________________
16.__________________________
17.__________________________
18.__________________________
19.__________________________
20.__________________________
21.__________________________
22.__________________________
23.__________________________
24.__________________________
25.__________________________
26.__________________________
27.__________________________
28.__________________________

__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________

_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________

I authorize Amcare Family Practice PA to download and review my medication history. When
available, my prescriptions may be electronically prescribed to the pharmacy listed above.
Patients Signature:_____________________________________ Date:___________________
Physicians Signature:___________________________________ Date:____________________
_____________________________________________________________________________
Statement of Financial Responsibility
I understand that I am responsible for the payment of this account and hereby assume and
guarantee prompt payment of all expenses incurred.
Notice of Non - Covered Services
I am aware that some services performed by Amcare Family Practice PA may be considered noncovered by my insurance carrier or Medicare, therefore, I will become fully responsible for these
services.
Permission of Treatment
Permission is hereby granted for Amcare Family Practice PA physicians and staf to render all
medical information to the following. I give authorization to discuss my protected health
information with the following:
Name:__________________________ Relationship:___________________ DOB:___________
Name:__________________________ Relationship:___________________ DOB:___________
Name:__________________________ Relationship:___________________ DOB:___________
Name:__________________________ Relationship:___________________ DOB:___________
Name:__________________________ Relationship:___________________ DOB:___________
Name:__________________________ Relationship:___________________ DOB:___________
Notice of Privacy Practices
8

I acknowledge that I have been provided with the Practices Notice of Privacy Practices that
provides a description of Protected Health Information uses and disclosures. I understand that I
have the right to review the Notice of Privacy Practices prior to signing this statement. I
understand that Amcare Family Practice PA reserves the right to change its Notice of Privacy
Practices that will be efective for health information the Practice already has about me, as well
as any they receive in the future. Amcare Family Practice PA will post a current copy of Notice
and I understand that I may obtain a copy of the current Notice in efect upon request.
Patient Receipt of HIPAA Privacy Notice
Dear Patient,
Amare Family Practice PA is committed to maintaining the integrity of your protected health
information and complies with all applicable state and federal regulations. The federal privacy
regulations of the Health Insurance Portability and Accountability Act (HIPAA) have taken efect
April 14, 2003. In support of our policy of complying with all applicable regulations, Amcare
Family Practice PA provides patients with the HIPAA Notice of Privacy Rights. While not required
in order to receive treatment at Amcare Family Practice PA, we are obliged under federal
regulations to ask that you sign an acknowledgement of the HIPAA Privacy Notice being make
available to you. Thank you, Receipt of HIPAA Privacy Notice I acknowledge receipt of the Notice
of Privacy Rights with detailed information about how Amcare Family Practice PA may use and
disclose my protected health information. I understand that Amcare Family Practice PA reserves
the right to change the privacy notice and that a copy of the revised notice will be made
available to me.

I have read all of the above and understand/agree to all provisions therein regarding
responsibility for payment, permission for treatment, and HIPAA Notice of Privacy Practices.

Patients Printed Name:__________________________________________________________

Patients Signature:____________________________________ Date:____________________
If Legal Guardian, Relationship to Patient:___________________________________________
***Office Use Only: To be completed only when patient declines to sign acknowledgement***
Check here is patient declined to sign acknowledgement
Staf Signature:_________________________________________ Date:___________________
*Refusal to sign acknowledgement does not prevent the patient from continuing to be treated.