PATIENT FORMS AND GUIDELINES

  • Patient Medical History
  • Quality of Life Assessment
  • Copy of Government ID
  • Credit Card Authorization
  • Patient Consent

Patient Medical History Form

Patient Name:
Date of Birth:
Gender:
Weight:
Height:

 

Section 1:

Patient History: Check all that apply to your current health as well as your past medical history.

 

Section 2:

(Female Only) Please check all that apply to you current or past medical history.

Have you had a hysterectomy? If yes, please provide the date and reason. 
Date of your last menstrual period?   

 

Section 3:

Please list the month and year of the most recent year you have had these tests performed.

Month:     Year:  
Month:     Year:  
Month:     Year:  
Month:     Year:  
Month:     Year:  
Month:     Year:  
Month:     Year:  
Month:     Year:  
Month:     Year:  
Month:     Year:  
Month:     Year:  
Month:     Year:  
Month:     Year:  
Month:     Year:  

Personal Physician Info:

Emergency Contact Info:

Specialist Physician Info:

Family History:

 

Section 4:

Past Surgical History:
Please list any medications you are currently taking:
Please explain any checked boxes on Section 1 of the medical history form
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Quality of Life Assessment

Patient Name:
Date of Birth:

Listed below are statements that people may make about themselves. Read the list carefully and mark YES if the statement applies to you. Mark the NO if it does not apply to you. Please answer every item.

If you are not sure whether to answer YES or NO, mark whichever answer most describes you in general. *

  1. I have to struggle to finish tasks:
  2. I feel a strong need to sleep during the day:
  3. I often feel lonely even when I am with other people:
  4. I have to read things several times before they sink in:
  5. It is difficult for me to make friends:
  6. It takes a lot of effort for me to complete simple tasks:
  7. I have a difficult time controlling my emotions:
  8. I often lose track of what I want to say:
  9. I lack confidence:
  10. I have to push myself to do things:
  11. I often feel very tense:
  12. I feel as if I let people down:
  13. I find it hard to mix with people:
  14. I feel worn out even when I've not done anything:
  15. There are times when I feel very low:
  16. I avoid responsibilities if possible:
  17. I avoid mixing with people I don't know well:
  18. I feel as if I'm a burden to people:
  19. I often forget what people have said to me:
  20. I find it difficult to plan ahead:
  21. I am easily irritated by other people:
  22. I often feel too tired to do the things I ought to do:
  23. I have to force myself to do all the things that need doing:
  24. I often have to force myself to stay awake:
  25. My memory lets me down:
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* Please make sure you answered YES or NO to every question

Copy of Government ID

Patient Name:
 

Please Make a Copy of Picture Identification

I Care Clinic requires a patient to supply our medical practice with a copy of a valid state identification or U.S Passport before they may begin a therapy program. A failure to supply I Care Clinic with identification will automatically disqualify a prospective patient from receiving treatment.

*Upload JPEG or PNG image format only:
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Credit Card Payment Authorization Form

Name:
Date:
Amount Purchased:
Credit Card Type:
Credit Card Number:
Credit Card Expiration Date:
Security Code:
Drivers License Number:
Billing Address:

City:
State:
Zip:
Telephone Home:
Telephone Work:
Shipping Address: (NO P.O. BOX NUMBERS)
(if different from billing)
City:
State:
Zip:
Telephone Home:
Telephone Work:
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Patient Consent for the Use & Disclosure of Health Information

Name:
Date:

If there is any person(s) in which you authorize to receive treatment or account status, please list name and relationship provided here:

Name:
Relationship:
Phone:
Name:
Relationship:
Phone:

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