New Patient Intake – Peak Vitality

  • Patient Information

  • Emergency contact:
  • Accident Information

  • Insurance Information

  • PLEASE PROVIDE THIS OFFICE WITH A COPY OF YOUR INSURANCE CARD(S)

  • Assignment and Release (Insured Patients) I certify that I (or my dependent) have insurance coverage with
  • and I AUTHORIZE, REQUEST AND ASSIGN MY INSURANCE COMPANY TO PAY DIRECTLY TO THE PHYSICIAN/MEDICAL PRACTICE, INSURANCE BENEFITS OTHERWISE PAYABLE TO ME. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the providers to release all information necessary, including the diagnosis and the records of any exam or treatment rendered to me, in order to secure the payment of benefits. I authorize the use of this signature on all insurance claims, including electronic submissions.
  • Main Complaints: (List in priority to you.)
  • Rate on a scale of 1-10:
  • Medical History

  • Women Only Health History

  • MENSTRUAL HISTORY
  • WOMEN’S DISORDERS / HORMONES
  • Mens Only Health History

  • Treatment History

  • PREVENTATIVE TEST AND DATE OF LAST TEST
  • SURGERIES AND DATE
  • Personal Habits

  • ACTIVITY
  • HABITS
  • What is your daily/weekly intake of the following?
  • Family Health History

  • IS THERE A FAMILY HISTORY OF ANY OF THE FOLLOWING CONDITION?
  • HOSPITALIZATIONS
  • MEDICATIONS
  • SUPPLEMENTS (Vitamins/Herbs/Homeopathy)
  • I certify that the above questions were answered correctly. I understand that providing incorrect information can be dangerous to my health.