Patient forms

New Patient Intake.

Help us get to know you before your first visit. The more complete this is, the more time we can spend on your care.

Patient Information

First Name *Last Name *Date of Birth *SexMarital StatusPreferred Language

Address

Street Address *

City *State *ZIP Code *

Phone & Employment

Home PhoneCell Phone *Email *EmployerOccupation

Family

Primary Care PhysicianReferring ProviderSpouse / Partner NameNumber of Children

Emergency Contact

Emergency Contact Name *Emergency Contact Relationship *Emergency Contact Phone *

Insurance

Insurance Provider *Member ID *Group NumberPolicy Holder NamePolicy Holder Date of BirthRelationship to Policy Holder

Driver's License / ID

Driver's License NumberIssuing State

Authorizations & Consent

I authorize AmpleHealth to treat me and provide medical care. *I authorize the release of my medical information to my insurance company for billing. *I authorize AmpleHealth to bill my insurance on my behalf. *I accept financial responsibility for charges not covered by my insurance. *I authorize AmpleHealth to leave appointment reminders and health messages on my voicemail. *I consent to receive communications by email and text message. *I acknowledge that I have received the Notice of Privacy Practices. *

Medical History

Please indicate whether you (Self) or a blood relative (Family) has had any of the following.

Condition	Self	Family
Diabetes	YesNo	YesNo
High blood pressure	YesNo	YesNo
Heart disease	YesNo	YesNo
Stroke	YesNo	YesNo
Cancer	YesNo	YesNo
Asthma / lung disease	YesNo	YesNo
Kidney disease	YesNo	YesNo
Liver disease	YesNo	YesNo
Thyroid disease	YesNo	YesNo
Depression / anxiety	YesNo	YesNo
Arthritis	YesNo	YesNo
Seizures	YesNo	YesNo

Other Medical Conditions

Hospitalizations & Surgeries

List any past hospital stays or surgeries.

Hospitalization 1 — ReasonHospitalization 1 — YearHospitalization 1 — Hospital

Hospitalization 2 — ReasonHospitalization 2 — YearHospitalization 2 — Hospital

Hospitalization 3 — ReasonHospitalization 3 — YearHospitalization 3 — Hospital

Hospitalization 4 — ReasonHospitalization 4 — YearHospitalization 4 — Hospital

Hospitalization 5 — ReasonHospitalization 5 — YearHospitalization 5 — Hospital

Current Medications

Medication 1 — NameMedication 1 — DosageMedication 1 — Frequency

Medication 2 — NameMedication 2 — DosageMedication 2 — Frequency

Medication 3 — NameMedication 3 — DosageMedication 3 — Frequency

Medication 4 — NameMedication 4 — DosageMedication 4 — Frequency

Medication 5 — NameMedication 5 — DosageMedication 5 — Frequency

Allergies

Allergy 1 — AllergenAllergy 1 — Reaction

Allergy 2 — AllergenAllergy 2 — Reaction

Allergy 3 — AllergenAllergy 3 — Reaction

Allergy 4 — AllergenAllergy 4 — Reaction

Allergy 5 — AllergenAllergy 5 — Reaction

Tests & Immunizations

Recent tests, screenings, or immunizations.

Test/Immunization 1 — NameTest/Immunization 1 — Date

Test/Immunization 2 — NameTest/Immunization 2 — Date

Test/Immunization 3 — NameTest/Immunization 3 — Date

Test/Immunization 4 — NameTest/Immunization 4 — Date

Test/Immunization 5 — NameTest/Immunization 5 — Date

Lifestyle

Smoking / TobaccoCaffeineAlcoholRecreational Drugs

Signature

Signature (type full legal name) *Date *

By submitting, you confirm the information above is accurate to the best of your knowledge.