Intake Form Sample - Delaware Integrative Medicine

PATIENT INFORMATION
Date Completed*
MM slash DD slash YYYY
Name*
First Name Last Name
Date of Birth*
MM slash DD slash YYYY
Gender*
- Male
- Female
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone
Cell Phone
Email*
Marital Status*
- Single
- Married
- Divorced
- Widowed
Employer Name
Employer Phone Number
How Did You Hear About Us?
Primary / Family Doctor
Doctor's Phone
EMERGENCY CONTACT
Emergency Contact Name
Relationship
Phone Number
PRIMARY MEDICAL INSURANCE
Company
Member ID
Group Number
Subscriber
Date of Birth
MM slash DD slash YYYY
SSN
MM slash DD slash YYYY
Relationship to Patient
- Self
- Spouse
- Parent
SECONDARY MEDICAL INSURANCE
Company
Member ID
Group Number
Subscriber
Date of Birth
MM slash DD slash YYYY
SSN
MM slash DD slash YYYY
Relationship to Patient
- Self
- Spouse
- Parent
CURRENT HEALTH CONDITION
Overall Health
- Excellent
- Good
- Fair
- Poor
Chief Complaint
Please briefly describe the reason you are here
Have you seen another doctor for this condition
- Yes
- No
WHO DID YOU SEE?
TYPE OF TREATMENT
WHEN DID THIS CONDITION BEGIN?
RESULTS
MEDICAL HISTORY
Please select the conditions that you have been diagnosed with.
- Rheumatic Fever
- Gall Blader Disease
- Heart Murmur
- Blood Clots
- Stroke
- Arthritis
- High Blood Pressure
- Anemia
- Elevated Cholesterol
- Cancer
- Varicose Veins
- Pneumonia
- Tuberculosis
- Broken Bones
- Kidney/Bladder Infection
- Diabetes
- Epilepsy/Seizure
- Stomach Ulcers
- Bronchitis or Asthma
- Thyroid Disease
- Emphysema
- Colon Disease
- Head/Spine Trauma
- Hepatitis
- Sports Related Injury
- Joint Disease
- HIV
Please list any surgical procedures you have undergone

Please list any surgical procedures you have undergone

PROCEDURE	DATE	HOSPITAL

Please list any medications you are currently taking including frequency and dosage:
Please list any allergies including drug allergies you have
FAMILY HISTORY
Relationship, Age, Health Problems
Please list family history according to the format above

List

RELATIONSHIP	AGE	HEALTH PROBLEMS

SOCIAL HISTORY
Please check all that apply
- Alcohol
- Drugs
- Tobacco/Cigarette
- Coffee
- Tea
- Soft Drinks
Please Note: Any Medical Emergencies - Please call 911 or Go to the Nearest Emergency Room
FINANCIAL DISCLOSURE

At Delaware Integrative Medicine, we have partnered with a few insurance companies in an attempt to lessen the financial burden on our patients. The insurance companies we partner with, typically cover office visits, technical fees involving injection, IV and Ultrasound tests. Most insurance companies do not cover expenses related to the administration of therapies used here to treat you including: ozone; UBI; PEMF; FSM; IV therapies (Myers, MAH, Glutathione, Chelation); saunas, etc.

You are responsible for any our-of-pocket expenses not covered by your insurance. If you do not have insurance, you are responsible for all fees including office visits and any additional fees.

If you default on any payment due, your account will be turned over to our collection agency. You are responsible for any fees or court costs as a result of our collection efforts. Late fee, charge and interest can be 18-24% as allowed by law
AGREEMENT*
- Click here to indicate that you have read and agree to the terms presented above.
Hidden
Date*
MM slash DD slash YYYY
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Or Call Us: 302-258-8853

PATIENT INFORMATION

EMERGENCY CONTACT

PRIMARY MEDICAL INSURANCE

SECONDARY MEDICAL INSURANCE

CURRENT HEALTH CONDITION

MEDICAL HISTORY

FAMILY HISTORY

SOCIAL HISTORY

Please Note: Any Medical Emergencies - Please call 911 or Go to the Nearest Emergency Room

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