Professional Documents
Culture Documents
NEW_PATIENT_HEALTH_HISTORY_FORM
NEW_PATIENT_HEALTH_HISTORY_FORM
Contact Phone
A ddress
NOTE: One to One Health must obtain y our written authorization to use y our Priv ate Health Information for any purpose other than treatment or
billing. If y ou want One to One Health to hav e access to disclose y our Priv ate Health Information to y our spouse or any other person during y our
treatment, please sign below.
____________________________________________________________________ ____________________________________
Patient Signature Date
Childhood illness: Measles Mumps Rubella Chick enpox Rheumatic Fev er Polio
Surgeries
A llergies to medications
ALL QUESTIONS CONTAINED IN THIS QUESTIONNA IRE A RE OPTIONAL AND WILL BE KEPT STRICTLY CONFIDENTIA L.
Occasional v igorous exercise (i.e., work or recreation, less than 4x/week for 30 min.)
If not try ing for a pregnancy list contraceptiv e or barrier method used:
Children M
Father F
M
Mother F
Sibling M M
F F
M M
F F
M Grandmother
F Maternal
M Grandfather
F Maternal
M Grandmother
F Paternal
M Grandfather
F Paternal
MENTAL HEALTH
A ge at onset of menstruation:
A ny urinary tract, bladder, or k idney infections within the last y ear? Yes No
Do y ou hav e menstrual tension, pain, bloating, irritability , or other sy mptoms at or around time of period? Yes No
MEN ONLY
Hav e y ou had any k idney , bladder, or prostate infections within the last 12 months? Yes No
OTHER PROBLEMS
Check if y ou hav e, or hav e had, any sy mptoms in the following areas to a significant degree and briefly explain.
Cell Phone
Work Phone
A ddress
Patient’s Name:_____________________________________________________________________
Our Notice of Privacy Practices provides information about how we may use and disclose protected health information
about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to
review our Notice before signing this Consent. The terms of our Notice may change, and if so you may obtain a
revised copy by contacting our office.
You have the right to request that we restrict how protected health information about you is used or disclosed for
treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we shall
honor that agreement.
By signing this form, you consent to our use and disclosure of protected health information about you for treatment,
payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However,
such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice
provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Protected health information may be disclosed or used for treatment, payment or health care operations. (
All other disclosures by the practice will require specific authorization by you unless required by law. (
The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice and
receive a copy. (
The Practice reserves the right to change the Notice of Privacy Policies. The new policy will be posted in the lobby
and on the web site. (
The patient has the right to restrict the uses of their information used for treatment, payment or operations, but the
Practice does not have to (agree to those restrictions.
Patient/Guardian:_______________________________________Date:___________________ (
Practice Representative:___________________________________Date:____________________ (