Patient Intake Form | Fini Health & Wellness

Patient Information

Today's Date First Name Last Name Middle Initial Date of Birth Age Gender Marital Status Occupation Social Security #

Address & Contact Details

Street Address City State Zip Code Home Phone Cell Phone Work Phone Email Address

Insurance Information

Insurance Carrier Primary Holder Name Primary Holder Date of Birth Effective Date Insurance ID # Group #

Responsible Party Information

Responsible Party Name Relationship to Patient Date of Birth Social Security # Employer Home Phone Work Phone Cell Phone Street Address City State Zip Code

Emergency Contact

Emergency Contact Name Relationship to Patient Home Phone Work Phone Cell Phone

Authorization & Acknowledgements

Authorization and Assignment of Benefits
I hereby give permission to United Medical Clinic of PA, LLC / Fini Health and Wellness Group, PLLC and its employees, agents, and medical providers to release medical information to health plans, health organizations, governmental agencies, and other entities charged with fiscal responsibility for the payment of medical services rendered to me. I authorize payment of medical benefits directly to the provider of services and understand that I am financially responsible for any charges not covered by insurance.

Patient Initials

Financial Policy

Insurance: Insurance coverage is a contract between the patient and the insurance company. The patient is responsible for supplying accurate, current insurance information and for knowing referral, authorization, network, deductible, copayment, and coinsurance requirements. Coverage is not a guarantee of payment.

Patient responsibility: Copayments and known balances are due when services are rendered. The patient or responsible party remains responsible for charges not paid by insurance, including denied or non-covered services. Returned checks are subject to a $35 fee. Form-completion requests may be subject to a $15 fee.

Appointments and collections: Please provide at least 24 hours' notice when cancelling. Missed appointments may result in a $25 fee for established patients or a $50 fee for new patients. Unpaid balances may be referred for collection, and the patient is responsible for permitted collection costs.

Financial Policy Initials

Financial Policy Signature (Full Name) Date

Patient Consent for Use and Disclosure of Protected Health Information

I consent to the use and disclosure of my protected health information for treatment, payment, and health-care operations. I understand that I may review the Notice of Privacy Practices, request reasonable restrictions, and revoke this consent in writing except where action has already been taken in reliance on it.

I authorize the practice to contact me about appointments, treatment, billing, and health-care operations using the methods I select below. Messages may be left only as authorized. I understand that ordinary email and text messaging may carry privacy risks.

People authorized to receive information (name, relationship, and phone) Authorized communication methods Home phoneCell phoneWork phoneVoicemailPostal mailEmailText message Special restrictions or confidential communication requests HIPAA / PHI Consent Initials

Patient / Guardian Full Name Relationship to Patient Patient Name (if signed by representative) Date

Allergies

Do you have any known allergies? No Known Allergies If yes, please list all Drug, Food, and Environmental Allergies

Medications

Please list all current Over-the-Counter and Prescribed Medications (include name, strength, and how often taken)

Preferred Pharmacy Pharmacy Location

Personal Medical History (Part 1)

Please indicate if you have had the following conditions in the past or currently.

Personal Medical History (Part 2)

Personal Medical History (Part 3)

Personal Medical History (Part 4)

Additional conditions listed in the current New Patient Packet.

Personal Medical History (Part 5)

Procedures & Surgeries

No procedures or surgeries Please list all procedures or surgeries and the year performed (Example: Tonsillectomy – 2005)

Family Medical History

Please indicate which family member(s) have or had the following conditions.

Family Medical History (Continued)

Social History

Pregnancy History

Please complete for all pregnancies including abortions, miscarriages, etc.

Pregnancy History (Date / Weeks Pregnant / Outcome / Length of Labor / Sex / Weight of Baby) Pregnancy anesthesia and hospital (for each pregnancy) Do you have a Living Will or Advanced Directive? YesNo

Employment & Education

Home & Environment

Nutrition & Health

Briefly describe your routine diet Type of Diet RegularLow FatCalorie RestrictedLow SodiumDiabeticRenalDysphagia DietTotal Parenteral NutritionKetogenic DietKosherVegetarianLow CarbohydrateOther Other diet details Vitamins / Supplements Uses Alternative Healthcare? RegularOccasionalNone Alternative healthcare type / details Eating Disorders BulimiaAnorexia NervosaOvereatingOther Other eating disorder details Diet Restrictions Caffeine intake amount Do you want to lose weight? YesNo Sleeping concerns? YesNo Feeling highly stressed? YesNo

Exercise & Physical Activity

How often do you exercise? Never1–2 times per week3–4 times per week5–6 times per weekDaily Exercise Type AerobicsBicyclingRunningSwimmingWalkingWeight LiftingYogaOrganized Team SportsPE ClassOther Duration (average minutes) Self Assessment PoorFairGoodExcellent Other exercise type Other Comments

Sexual Activity & History of Abuse

Are you sexually active? YesNo Age when first sexually active Number of lifetime partners Number of current partners Sexual Orientation HeterosexualBisexualHomosexualTransgenderOther Self-describe orientation (if other) Do you use condoms? YesNo Contraceptive Use AbstinenceCondomsBirth Control PillBirth Control PatchBirth Control ShotIntrauterine Device (IUD)ImplantVaginal RingNone Other Contraceptive Use / Comments Have you ever been sexually abused? YesNo Comment Other orientation, identity, safety, or abuse-related concerns

Final Certification

I certify that the information contained herein is complete and accurate to the best of my knowledge.

Patient Signature (Full Name) Date