Client Intake Questionnaire

Page 1

Full Name

Nombre

Apellido

Phone Number

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Birth Date

Gender

Employer

E-mail

Occupation

Marital Status

Spouse's Name

Spouse's Occupation

Spouse's Employer

Emergency Contact

Emergency Contact Phone Number

Primary Care Provider

Primary Care Provider Phone Number

How were you referred to our office?

Page 2

How I plan to pay for treatment:

Cash Credit Card Insurance Payment Plan

Gift card/promotional number

Page 3

Are you experiencing any of the following? (Please check all that apply)

List any major illnesses or hospitalizations:

What medications or drugs are you taking?

Have you been treated for any health conditions in the last year?

Yes No

List any other health problems, no matter how insignificant they may be:

Page 4

Purpose of this appointment:

Have you ever had the same or a similar problem?

Yes No

If yes, please describe:

Page 5

Do you do any of the following? (Please check all that apply)

Smoke Drink Alcohol Exercise Regularly Other

If you checked any of the options above, please detail below:

What are your hobbies?

Page 6

Do any of your family members suffer from these? (Please check all that apply)

Page 7

I authorize the release of any medical information needed to process claims with my insurance carrier.

I authorize my medical insurance benefits to be paid directly to this office for services rendered.

I understand I am responsible for any balance not covered by my insurance.

I agree to promptly inform the office of any changes to my insurance or contact details.

I confirm I have read and understood the financial policy outlined above.

Page 8

I certify that the information I have provided on this form is accurate and complete to the best of my knowledge.

By signing below, I authorize treatment and agree to the terms described in this form.

Patient's Signature

Date

When the patient is a minor, the signature of a parent or legal guardian is required.

The parent or guardian confirms they hold legal authority to authorize treatment for the minor.

Parent/Guardian Signature