Custom EMR For Circle Wellness

Behrouz Farahmandpour D.O., P.C.
25 Melville Park Rd, Suite 200 B, Melville, NY 11747
+1 888-293-5577 | [email protected]

PATIENT INTAKE FORM

Patient Information

Insurance & Emergency Contact

Pain and Health Assessment

Today's Date:

New Patient

Established patient, updated

ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES

I acknowledge that I was provided with a copy of the Circle Wellness Notice of Privacy Practice Yes

PATIENT INFORMATION

First Name *

Middle Name

Last Name *

DOB *

Gender *

Email Address *

No email available

Primary Phone Number *

No phone number available

Secondary Phone

Preferred Method of Contact

Address

City

State

Zip

Employer

Are you seeing us as the result of a car accident (No-Fault Case)?

Are you seeing us as the result of a work-related accident (Worker's Compensation Case)?

No, this is not related to an accident.

Upload Driving License:

INSURANCE INFORMATION

Same as Patient

Primary Insurance Carrier

ID#

First Name

Middle Name

Last Name

Policy Holder’s DOB

Policy Holder’s Relationship to Patient

Policy Holder’s Phone Contact Number

Upload Insurance Document:

Have you had prior episodes of back symptoms for which you received Worker’s Compensation or No-Fault for?

Yes

Secondary Insurance

No-Fault (Car Accident) Information

REFERRAL INFORMATION

How did you hear about us?

EMERGENCY CONTACT INFORMATION

Emergency Contact Name

Relationship to patient

Primary Contact Number

Secondary Contact Number

Please check off which areas you are having pain in:

Check appropriate areas of your body where you NOW feel your typical pain.

Include all affected areas. (Check all that apply)

FRONT SIDE	YES	NO	LEFT	RIGHT	BOTH	PAIN	NUMBNESS
Neck
Chest
Shoulder
Arms
Abdomen
Hips
Thighs
Knees
Ankles
Feet

Check appropriate areas of your body where you NOW feel your typical pain.

Include all affected areas. (Check all that apply)

BACK SIDE	YES	NO	LEFT	RIGHT	BOTH	PAIN	NUMBNESS
Neck
Upper Back
Lower Back
Shoulders
Hips
Thighs
Knees
Calves
Ankles
Feet

PATIENT RESPONSE TO PREVIOUS TREATMENTS	BETTER	WORSE	NO CHANGE
Hot packs/ice
Ultrasound
Massage
TENS/Electrical Stimulation
Yoga/Tai-Chi
Exercises
Traction/DRS
Bed Rest
Pool Therapy
Biofeedback
Injections
Braces/Splints
Medication
Acupuncture
Chiropractic Adjustments

REVIEW OF SYSTEMS (Check all that apply)

MEDICAL HISTORY Have you ever had: (Check all that apply)

PAST SURGICAL HISTORY

Year	Operation

Additional Past Surgical History

ALLERGIES

Medication/Food/Other	Type of Reaction

Add additional allergy details

MEDICINES

Medication Name	Dosage	Frequency	Purpose

Add additional medications

FAMILY HISTORY

Relation	Age	Living Status	Health Issues
Mother
Father
Siblings

Add additional family history

SOCIAL HISTORY

Add additional social history

MARITAL STATUS

How many years?

Number of children?

Ages:

Who lives with you at home?

By submitting this form, you agree to our Privacy Policy, Terms of Service and consent to receive our SMS messages.

Tobacco use:	Yes No	How Often:
Alcohol:	Yes No	How Often:
Illicit drug use:	Yes No	How Often:
Caffeine:	Yes No	How Often:
Exercise:	Yes No	How Often:

PATIENT INTAKE FORM

ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES

PATIENT INFORMATION

INSURANCE INFORMATION

SECONDARY INSURANCE INFORMATION

NO-FAULT (CAR ACCIDENT) INFORMATION

REFERRAL INFORMATION

EMERGENCY CONTACT INFORMATION

Please check off which areas you are having pain in:

Check appropriate areas of your body where you NOW feel your typical pain.

Check appropriate areas of your body where you NOW feel your typical pain.

REVIEW OF SYSTEMS (Check all that apply)

CONSTITUTIONAL

HEMO-LYMPHATIC

ALLERGY/IMMUNE

CARDIAC/RESPIRATORY

NEUROLOGIC

GASTROINTESTINAL

MUSCULOSKELETAL

ENDOCRINE

HEAD/EYES

SKIN/INTEGUMENTARY

URINARY/GYN

PSYCHIATRIC

MEDICAL HISTORY Have you ever had: (Check all that apply)

PAST SURGICAL HISTORY

ALLERGIES

MEDICINES

FAMILY HISTORY

SOCIAL HISTORY

MARITAL STATUS