Functional Intake Form - Life Balance Medical Center

First Name *

Last Name

Email*

Phone*

Date

DOB

Sex

Home phone

Patient's Address info

Occupation:

Employer Name:

Spouse or guardian’s name :

Whom may we thank for referring you?

Spouse’s Employer:

Person to contact in case of emergency:

Full name

Phone

In case of a medical emergency, if the patient is of school age 15+, is ok to treat in my absence.
Full Name

Date of birth

Responsible Party

Name of the person responsible for this account:

Relationship to patient:

Address

Responsible's Home Phone:

Responsible's email

Responsible's cell phone:

Driver’s License #

Responsible's date of birth

Is the person currently a patient at our office? YesNo

Do you have any Medical insurance? NoYes( if yes, complete the following:)

ASSIGNMENT OF HEALTH PLAN BENEFITS AND RIGHTS AS WELL AS AN APPOINTMENT AND/OR DESIGNATION AS MY PERSONAL REPRESENTATIVE AND AN ERISA/PPACA REPRESENTATIVE AND BENEFICIARY

I understand and agree that (regardless of whatever health insurance or medical benefits I have), I am ultimately responsible to pay Life Balance Medical Center, Inc. as well as all employees, employers, representatives, and agents thereof, (hereinafter collectively referred to as “Healthcare Provider”) the balance due on my account for any professional services rendered and for any supplies, tests, or medications provided. I hereby authorize payment of, and assign my rights to, any health insurance or medical plan benefits directly to Healthcare Provider for any and all medical/ healthcare services, supplies, tests, treatments, and/or medications that have been or will be rendered or provided; as well as designating and appointing Healthcare Provider as my beneficiary under all health insurance or medical plans which I may have benefits under. I hereby authorize the release of any health status, conditions, symptoms or treatment information contained in your records that is needed to file and process insurance or medical plan claims, to pursue appeals on any denied or partially paid claims, for legal pursuit as to any unpaid or partially paid claims, or to pursue any other remedies necessary in connection with same. I hereby assign directly to Healthcare Provider all rights to payment, benefits, and all other legal rights under, or pursuant to, any health plan (including, but not limited to, any ERISA governed plan/insurance contract, PPACA governed plan/ insurance contract) rights that I (or my child, spouse, or dependent) may have under my/our applicable health plan(s) or health insurance policy(ies). I also hereby appoint and designate that Healthcare Provider can act on my/our behalf, as my/our Personal Representative, ERISA Representative, and PPACA Representative as to any claim determination, to request any relevant claim or plan information from the applicable health plan or insurer, to file and pursue appeals and/or legal action (including in my name and on my behalf) to obtain and/or protect benefits and/or payments that are due (or have been previously paid) to either Healthcare Provider, myself, and/or my family members as a result of services rendered by Healthcare Provider, and to pursue any and all remedies to which I/we may be entitled, including the use of legal action against the health plan, the insurer, or any administrator. I hereby also declare that Healthcare Provider is my/our beneficiary regarding my/our health plan as contemplated by both ERISA and PPACA, and that Healthcare Provider can pursue any and all rights that I/we may have under state and/or federal law regarding my/our health plan. This assignment, appointment, and designation will remain in effect unless revoked by me in writing. It is my intent that the effective date of this document shall relate back to include all services, supplies, test, treatments, or medications that have been previously provided by Healthcare Provider. A photocopy or scan or this document is to be considered as valid and as enforceable as the original.

Signed this

Date of 2023

Print patient/guardian name

Patient/guardian signature

Health History

Patient Name:

First Name

Second Name

DOB

Patient date

Chief Complaint

Primary Care Physician

History of Present illness

Location of problem

Severity

Timing:

What other areas of your body are affected by this problem?

What have you tried in the past to handle your problem?

Duration:

What activities have you given up or changed due to this problem?

What activities increase symptoms/makes problems worse?

Previous Hospitalizations/Surgeries/Serious Illnesses:

When ?

Hospital, City, State

Medication Name (include OTC)

Medication Name

Strength/Dosage

Reason taking it

Supplement Name/Brand

Supplement Name/Brand

Strength/Dosage

Reason taking it

Primary Care Physician

Have you ever taken Fen-Phen/Redux? YesNo

Are you taking any medications (prescription or over the counter) for acid indigestion? NoYes

Do you have a sulfa allergy? YesNo

CLINICIAN SIGNATURE:

DATE REVIEWED:

Patient Social History:

Use of Alcohol NeverRarelyModerateDaily

Use of Tobacco NeverRarelyModerateDaily

Use of Drugs NeverType/Frequency

Please list any allergies:

Do you exercise: FrequentlyModeratelyOccasionallyNone

Does your work activity mostly involve? SittingStandingLight LaborHeavy Labor

Have you ever been exposed to mold? YesNo

Have you ever been exposed to chemicals (work, pesticides, etc.)? NoYes

Sleep/Rest:

Average number of hours you sleep? More than 108 to 106 to 8Less than 6

Do you have trouble sleeping? YesNo

Do you have problems falling asleep? YesNo

Do you have problems staying asleep ? YesNo

Do you feel rested upon awakening? YesNo

Do you have problems with insomnia? YesNo

Do you snore? YesNo

Do you use sleeping aids? YesNo

Dental History:

Do you have (or had) any non-tooth colored fillings (i.e. silver or gold colored fillings)? YesNo

Have you had any fillings removed? YesNo

Do you have any root canals? YesNo

Other dental fixtures? YesNo

Have you had any dental work in the last 12 months? Please describe.

Do you have a Pacemaker? YesNo

Do you have a Defibrillator ? YesNo

Do you have a Living will? YesNo

Do you have a DNR? (DO NOT RESUSCITATE) YesNo

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor’s office of any changes in my medical status. I also authorize the healthcare staff to perform the necessary services I may need.

Signature of the Patient, Parent or Guardian

Date

Signature of person holding POA for patient

Date

Doctor’s Review

Signature of Doctor

Date

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.