Patient Intake Form Name(Required) First Last Today's Date(Required) Month Day Year Date of Birth(Required) Month Day Year SSNAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneWork PhoneCellEmail Preferred Method of Communication Text Email Phone Call Emergency Contact First Last RelationshipHome PhoneWork PhoneCellEmployerEmployer Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Care ProviderPrimary Care Provider Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Current Health Concerns and Diagnoses:Please List Current Problems and/or Symptoms:Allergies:ExerciseDo you feel motivated to exercise? Yes A little No Are there any problems that limit exercise? Yes No If yes, please explainNutritionList the current diet or nutritional program that you follow:List current food allergies or sensitivities:List any foods you crave or binge on:SleepList any sleep problems including falling asleep, staying asleep, insomnia and/or snoring:Stress:On a scale of 1-10, with 10 being the highest, what is your current stress level?Can you easily manage the stress in your life? Yes No SmokingDo you currently smoke? Yes No AlcoholHow many alcoholic beverages do you drink in a day/week?Environmental/Detoxification History:List any Environmental Toxins that you are sensitive to:List any Environmental Toxins that you are currently exposed to in your work environment or have been exposed to in the past:List any significant previous exposure to any harmful chemicals:Family History for Disease (list):Past Medical History (list):Current Prescription Medications with Dosages (list):Current Supplements with Dosages (list):Review of Symptoms: What are your current Problems/Symptoms with the past 6 months:Health Care Goals:List your health care goals and what you hope to achieve in your visit with us?HIPPA Acknowledgement and Consent Form Purpose of Consent: I understand that I have certain rights to privacy regarding my protected health information, under the Health Insurance Portability and Accountability Act of 1966 (HIPAA). By signing this form, you consent to our use and disclosure of your protected health information to carry out treatment, payment activities and healthcare operations. Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this consent. The notice describes how we may use and disclose your protected health information and other important matters about your protected health information. A copy of our Notice accompanies this consent. We encourage you to read it carefully and completely before signing this consent. You may obtain a copy of our Notice of Privacy Practices at any time by contacting: 208-263-1408 Sandpoint Super Drug Clinical Services 604 North 5th Ave Sandpoint, Idaho 83864. Right to Revoke: You have the right to revoke this consent at any time by giving us written notice of your revocation submitted to the above contact person. Revocation of this consent will not affect any action we took in reliance of this consent prior to receiving your revocation. Signature: I have had the opportunity to read and consider the contents of this consent form and your Notice of Privacy Practices. I understand that, by signing this consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations. SignatureNameThis field is for validation purposes and should be left unchanged.
