Patient Intake Form s1

Acadia Integrative Medicine Patient Intake Form

Name: ______Date of birth: ______What do you prefer to be called? ______Mailing Address: ______Email: ______Cell-Phone: ______Home-Phone: ______

May we send you reminders by: Email? Yes No Phone? Yes No Text? Yes No

How do you prefer to be contacted? Email Phone Mail Occupation: ______Ethnicity:______Emergency Contact Name: ______Phone: ______

Insurance Company: ______Phone : ______Claim Address on card: ______Name of Guarantor______Guarantor's Birthdate ______Group ID # ______ID # ______Co-Pay or Co-insurance amount ______

What pharmacy do you use? ______

Do you give Dr. Seed permission to retrieve your prescription history from your pharmacy? Yes No

The state has an immunization registry to keep record of immunizations, do you need your immunization data protected or may it be included in the registry? Include my data in the registry Do NOT include my data in the registry

Please list all of your medications, the dose you take and how often you take them below: (continue on back of page if necessary) Supplement list; please list what and how much you take:

Please list any allergies to medications and what reaction you had:

Do you smoke or are you a former smoker? If so, how much do you smoke in a day?

Please list all current and past medical problems.

Please list any hospitalizations/surgeries (please include childbirth).

Please tell us about your family history. Relation Medical Problem Mother Father Siblings

Mark all special studies you have had in the last five years and indicate an approximate date. □Sleep Study ______□PAP Smear ______□STD testing ______

□Colonoscopy ______□Stool Blood Test ______□Mammogram ______

□MRI ______□CT scan ______□Ultrasound ______

□X-ray ______□DEXA/ bone density ______□ECG/ EKG ______Indicate if you have had any of the following vaccines and the date it was last administered.

□Tetanus (Tdap) ______□Pneumovax (pneumonia vaccine) ______

□Flu Shot ______□Zostavax (shingles vaccine) ______

□Hepatitis A ______□Hepatitis B ______

Please list all medical professionals you are currently working with/seeing.

What do you do for fun?

What are your some of your health goals?