Patient Information First Name Last Name Middle Initial Date of Birth Age Gender MaleFemaleOther 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 Effective Date Insurance ID # Group # Responsible Party Information Responsible Party Name Relationship to Patient Date of Birth 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 Acknowledgement I acknowledge that I have received and reviewed the Financial Policy of United Medical Clinic of PA, LLC / Fini Health and Wellness Group, PLLC and understand it is my responsibility to provide accurate demographic, insurance, and medical information. Patient Initials HIPAA Privacy Acknowledgement I acknowledge that I have received and reviewed the Notice of Privacy Practices from United Medical Clinic of PA, LLC / Fini Health and Wellness Group, PLLC. Patient Initials Patient / Guardian Full Name 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. Condition Past Current Date / Age (Onset or Resolved) Abdominal Pain – Chronic Past Current Agitation Past Current Alcohol Abuse / Addiction Past Current Allergies Past Current Anemia Past Current Arthritis Past Current Asthma Past Current Back Pain – Recurrent Past Current Bleeding Easily Past Current Blood in Urine (Hematuria) Past Current Bloody or Tarry Stools Past Current Bone Fracture / Joint Injury Past Current Cancer Past Current Cataracts Past Current Chest Pain Past Current Chicken Pox Past Current Chronic Cough Past Current Chronic Fatigue Past Current Cold / Numb Feet Past Current Colitis Past Current Constipation Past Current Crohn's Disease Past Current Personal Medical History (Part 2) Condition Past Current Date / Age (Onset or Resolved) Decrease in Flow or Force of Urine Past Current Decreased Hearing Past Current Depression / Moodiness Past Current Diabetes Past Current Diarrhea Past Current Difficulty Swallowing Past Current Diverticulosis Past Current Dizzy Spells Past Current Double or Blurred Vision Past Current Drug Abuse / Addiction Past Current Ear Infections – Frequent Past Current Eczema Past Current Epilepsy Past Current Eye Pain Past Current Failing Vision Past Current Fainting Spells Past Current Feelings of Worthlessness Past Current Foot Pain Past Current Gall Bladder Trouble Past Current German Measles Past Current Glaucoma Past Current Gout Past Current Headaches / Migraine Past Current Personal Medical History (Part 3) Condition Past Current Date / Age (Onset or Resolved) Heart Disease Past Current Heart Murmur Past Current Heartburn Past Current Hemorrhoids Past Current Hernia Past Current Herpes Past Current High Blood Pressure Past Current High Cholesterol Past Current Hoarseness – Prolonged Past Current Irregular Pulse / Palpitations Past Current Jaundice / Hepatitis Past Current Kidney Stones Past Current Leg Pain When Walking Past Current Loss of Appetite – Recent Past Current Loss of Bladder Control Past Current Measles Past Current Memory Loss Past Current Mental Illness Past Current Mumps Past Current Nervousness Past Current Nose Bleeds – Frequent Past Current Numbness / Tingling Past Current Osteoporosis Past Current Other (Specify Below) Past Current Procedures & 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. Condition Immediate Family Maternal Side Paternal Side Alcohol Abuse MotherFatherSisterBrother GrandmotherGrandfather GrandmotherGrandfather Allergies MotherFatherSisterBrother GrandmotherGrandfather GrandmotherGrandfather Anemia MotherFatherSisterBrother GrandmotherGrandfather GrandmotherGrandfather Arthritis MotherFatherSisterBrother GrandmotherGrandfather GrandmotherGrandfather Asthma MotherFatherSisterBrother GrandmotherGrandfather GrandmotherGrandfather Cancer (Specify Type) MotherFatherSisterBrother GrandmotherGrandfather GrandmotherGrandfather If Cancer, please specify type(s) Diabetes MotherFatherSisterBrother GrandmotherGrandfather GrandmotherGrandfather Epilepsy MotherFatherSisterBrother GrandmotherGrandfather GrandmotherGrandfather Glaucoma MotherFatherSisterBrother GrandmotherGrandfather GrandmotherGrandfather Headache / Migraine MotherFatherSisterBrother GrandmotherGrandfather GrandmotherGrandfather Family Medical History (Continued) Condition Immediate Family Maternal Side Paternal Side Heart Disease MotherFatherSisterBrother GrandmotherGrandfather GrandmotherGrandfather High Blood Pressure MotherFatherSisterBrother GrandmotherGrandfather GrandmotherGrandfather High Cholesterol MotherFatherSisterBrother GrandmotherGrandfather GrandmotherGrandfather Mental Illness MotherFatherSisterBrother GrandmotherGrandfather GrandmotherGrandfather Osteoporosis MotherFatherSisterBrother GrandmotherGrandfather GrandmotherGrandfather Severe Depression MotherFatherSisterBrother GrandmotherGrandfather GrandmotherGrandfather Stroke MotherFatherSisterBrother GrandmotherGrandfather GrandmotherGrandfather Thyroid Disease MotherFatherSisterBrother GrandmotherGrandfather GrandmotherGrandfather Other Family Conditions (Specify) Social History Alcohol Use CurrentPastNever If quit alcohol, when? Tobacco Use CurrentPastNever If quit tobacco, when? Substance / Drug Use CurrentPastNever If quit substance use, when? Exercise & Physical Activity NoneOccasionalRegular Amount / Frequency of Exercise Pregnancy History Please complete for all pregnancies including abortions, miscarriages, etc. Pregnancy History (Date / Weeks Pregnant / Outcome / Length of Labor / Sex / Weight of Baby) Example: 2018 Do you have a Living Will or Advanced Directive? YesNo Employment & Education Employment Status EmployedPart-TimeUnemployedStudentRetiredDisability Do you operate hazardous equipment? YesNo Previous Employment / School Work Hazards Hazardous MaterialsRepetitive MotionHeavy Lifting / TwistingLoud NoisesMedical / Clinical WorkShift / Night WorkVibration Highest Education Level NoneElementary SchoolMiddle SchoolHigh School / GEDSome CollegeBachelor's DegreeMaster's DegreeAdvanced Graduate / PhD Home & Environment Lives With SelfSpouseChildrenFamilyMotherFatherSiblingsGrandparentsRoommate / FriendsSignificant OtherFoster Family Living Situation Home / IndependentHome with AssistanceHomeless / Shelter Do you feel unsafe at home? YesNo Do you have a safe place to go? YesNo Do you have family or friends available to help? YesNo Have you experienced abuse in your household? YesNo If yes, have you notified any agencies? YesNo Agencies / Others Notified Nutrition & Health Briefly describe your routine diet Describe your daily diet Type of Diet RegularLow FatCalorie RestrictedLow SodiumDiabeticRenalDysphagia DietTotal Parenteral NutritionKetogenic DietKosherVegetarianLow CarbohydrateOther Vitamins / Supplements Uses Alternative Healthcare? RegularOccasionalNone Eating Disorders BulimiaAnorexia NervosaOvereatingOther 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 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 Final Certification I certify that the information contained herein is complete and accurate to the best of my knowledge. Patient Signature (Full Name) Date
