NEW PATIENT INTAKE FORM PATIENT INFORMATION Patient’s First Name * First Middle Initial MI Last Name * Last Gender * SelectMaleFemale Date of Birth: * Social Security Number Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal PARENT|LEGAL GUARDIAN First Name Parent | Legal Guardian First Name/Middle Name Last Name Parent | Legal Guardian Last Name Relation to Client Relation to Client Phone Email REFERRING SOURCE Physician Full Name * Full Name Phone * Fax REASON FOR REFERRAL | DIAGNOSTIC PRIMARY INSURANCE *** MUST BE FILL *** PRIMARY INSURANCE * PHONE POLICY NUMBER * GROUP POLICY HOLDER * RELATION TO PATIENT POLICY HOLDER’S DAY OF BIRTH POLICY HOLDER’S SS# POLICY HOLDER’S EMPLOYER SECONDARY INSURANCE arrowup6 Fill if you have a secondary insurance SECONDARY INSURANCE PHONE POLICY NUMBER GROUP POLICY HOLDER RELATION TO PATIENT POLICY HOLDER’S DAY OF BIRTH POLICY HOLDER’S SS# POLICY HOLDER’S EMPLOYER YOUR HEALTH CARE PROVIDER, INSURER, OR PLAN MAY REQUIRE A PHYSICIAN REFERRAL OR PRIOR AUTHORIZATION AND YOU MAY BE OBLIGATED FOR PARTIAL OR FULL PAYMENT FOR SERVICES PROVIDED. PATIENT HISTORY YOUR PAST MEDICAL HISTORY * Diabetes Hypertension Renal Disease (kidney disease) High Cholesterol COPD, Bronchitis, Emphysema or Asthma Hypothyroidism (low thyroid) Coronary Artery Disease/ Heart Attack Depression or Anxiety CHF (Heart Failure) GERD or Peptic Ulcers Pacemaker /Defibrillator Cirrhosis or Hepatitis A FIB or Mechanical Valve (type) Rheumatoid Arthritis PVD, PAD, or DVT Gout or Osteoarthritis Stable Chest Pain (using Nitro) Erectile Dysfunction or BPH Stroke or TIA Sleep Apnea Seizure, Parkinson Disease, Epilepsy Cataracts or Glaucoma Dementia or Alzheimer Disease Cancer History of STD’s OtherOther REVIEW OF SYMPTOMS Vision problems Wheezing Loud Snoring Spinning/ Vertigo Diarrhea Hearing problems Cough/Coughing blood Breast Lumps/Discharge Memory Loss Sinus trouble Constipation Shortness of breath Testicle Lump Balance problems Rectal bleeding Hay fever TB exposure Frequent Urination Trouble swallowing Dark Colored Stool Nosebleeds Palpitations Incontinence Excessive hunger Hives Sore throat Chest pain / discomfort Blood in Urine Excessive thirst Rash Hoarseness Dizziness Kidney stones Heat / Cold intolerance Lumps in neck Leg Swelling Anemia Excessive Sweating Tooth problems Poor Circulation Easy bruising High blood sugar Earache / Discharge Cold / burning Feet Joint pain / stibness Low blood sugar readings Runny Nose / Congestion Discomfort in legs when walking Tremor Nausea Fever / Chills Weakness Fainting Vomiting Weight loss / gain Dificulty sleeping Decrease/ Increased Appetite Sweats/ Fatigue Increased daytime sleepiness Hallucinations Abdominal Pain Anxiety / Depression Falling asleep watching TV Headaches Heartburn Please’ List Others:Please’ List Others: Please review the following symptoms and check those items that are a problem for you in the past 3-6 month FAMILY HEALTH HISTORY Please list below the health history of your blood (genetic) first degree relatives Relative Living or Deceased Please choseAliveDeceased Current age or age at death Health Problems Cause of Death Relative Living or Deceased AliveDeceased Current age or age at death Health Problems Cause of Death Relative Living or Deceased AliveDeceased Current age or age at death Health Problems Cause of Death Relative Living or Deceased AliveDeceased Current age or age at death Health Problems Cause of Death Relative Living or Deceased AliveDeceased Current age or age at death Health Problems Cause of Death Relative Living or Deceased AliveDeceased Current age or age at death Health Problems Cause of Death Relative Living or Deceased AliveDeceased Current age or age at death Health Problems Cause of Death Relative Living or Deceased AliveDeceased Current age or age at death Health Problems Cause of Death Relative Living or Deceased AliveDeceased Current age or age at death Health Problems Cause of Death I was adopted Yes, I was adopted OtherOther HOSPITALIZATIONS WITHIN THE PAST ONE (1) YEAR Hospitalization Reason Month/Yr. Hospitalization Reason Name of Hospital Month/Yr. Month/Yr. Name of Hospital Month/Yr. plus1 Add minus1 Remove PAST SURGICAL PROCEDURES Hospitalization Reason Month/Yr. Name of Hospital Month/Yr. plus1 Add minus1 Remove DISEASE PREVENTION AND HEALTH MAINTENANCE Please list below the most recent dates of your vaccines and health screening tests Month/Yr Month/Yr Month/Yr Month/Yr Month/Yr Month/Yr Month/Yr Month/Yr Month/Yr Month/Yr Month/Yr Month/Yr PATIENT SERVICE AGREEMENT Patient Service Agreement between below “Parent/Legal Guardian” and “Therapy” * INITIALS: PARENT/LEGAL GUARDIAN Date * New Patient Consent to the Use and Disclosure of Health Information for Treatment, Payment or Healthcare Operations I, * ( the term “I” refers to the Parent/Legal Guardian of child) understand that as part of my healthcare, “Carrousel Health Care Corporation,” originates and maintains paper and/or electronic records describing “my” (the term “my” refers to parent and/or child) health history, symptoms, examinations and test results, diagnoses, treatment, and any plans for future care of treatment. I understand that this information serves as: -A basis for planning my care and treatment, -A means of communication among the many health professionals who contributes to my care, -A source of information for applying my diagnosis and surgical information to my bill, -A means by which a third-party payer can verify that services billed were actually provided, and -A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcareprofessionals. I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges: -The right to review the notice prior to signing this consent, -The right to object to the use of my health information for directory purposes, and -The right to request restrictions as to how my health information may be used or disclosed to carry out treatment,payment, or healthcare operations. I understand that “Therapy,” is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already take action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations. I further understand that “Therapy,” reserves the right to change their notice and practices and prior to implementation, in accordance with Section 164.520 of the Code of Federal Regulations. Should “Therapy,” change their notice, they will send a copy of any revised notice to the address I’ve provided (whether U.S. mail or if I agree e-mail). I wish to have the following restrictions to the use or disclose of my health information: I understand that as part of this organization’s treatment, payment, or healthcare operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via fax and/or e-mail. I fully understand and accept the terms of this consent. * Patient/Parent/legal Guardian’s Initials Date * HIPPA Release Form I, * Print Name Of Patient Parent/Guardian of Patient: * give permission to “CARROUSEL HEALTH CARE CORPORATION.” and all employees to discuss and/or receive medical information including medical records concerning any and all aspects of patient’s previous healthcare by a doctor, physical, occupational or speech therapist, or other medical professional. This release is required to obtain medical information according to the privacy rule detailed in HIPPA (The Health Insurance Portability and Accountability Act of 1996). Patient Date of Birth: * Patient’s Social Security: Parent/Guardian’s Signature: * Date * Submit If you are human, leave this field blank. Δ
