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Insurance Information

Insurance Subscriber Name

Social Security Number

Date of Birth

Phone Number

Email Address

Address

City

State

Zip Code

Primary Insurance

Primary Insurance Carrier

Phone Number

the one providers should call

ID Number

Group Number

Secondary Insurance

Secondary Insurance Carrier

Phone Number

the one providers should call

ID Number

Group Number

Guarantor (Financially Responsible Party) Information

Name

Social Security Number

Date of Birth

Phone Number

Email Address

Address

City

State

Zip Code

Health Information

Height (Feet)

Height (Inches)

Current Weight

in pounds

Amount of Weight Change (+/-) in the Last Six Months

Highest Adult Weight (Outside of Pregnancy)

in pounds

Age When At This Weight

Lowest Adult Weight

in pounds

Age When At This Weight

Weight Comments

If you require a vegetarian diet, please provide details.

Please list any food restrictions that you observe as part of your religion.

Please list any food intolerances.

Allergies

Please list all of your food and non-food allergies. Medical documentation for food allergies is required.

Allergy / Reaction

e.g., dogs / itchy eyes, sneezing

Do you have medical documentation for these allergies?

Yes

Current medications (prescribing physician, name of medicine, dosage, reason for use)?

Please note: Some medications may be altered or withdrawn after your meeting with our medical team.

Substance Abuse History

Fill out below where applicable.

Marijuana Use

Date of Last Marijuana Use

Frequency of Marijuana Use

Average Marijuana Use Amount

Cocaine/Crack Use

Date of Last Cocaine/Crack Use

Frequency of Cocaine/Crack Use

Average Cocaine/Crack Use Amount

Methamphetamine Use

Date of Last Methamphetamine Use

Frequency of Methamphetamine Use

Average Methamphetamine Use Amount

Amphetamine Use

(e.g., Adderall)

Date of Last Amphetamine Use

Frequency of Amphetamine Use

Average Amphetamine Use Amount

Barbiturate Use

(e.g., Amytal, Nembutal, Seconal)

Date of Last Barbiturate Use

Frequency of Barbiturate Use

Average Barbiturate Use Amount

Heroin Use

Date of Last Heroin Use

Frequency of Heroin Use

Average Heroin Use Amount

PCP Use

Date of Last PCP Use

Frequency of PCP Use

Average PCP Use Amount

Hallucinogen Use

Date of Last Hallucinogen Use

Frequency of Hallucinogen Use

Average Hallucinogen Use Amount

Benzodiazepene Use

(e.g., Valium, Ativan, Xanax)

Date of Last Benzodiazepene Use

Frequency of Benzodiazepene Use

Average Benzodiazepene Use Amount

Inhalant Use

Date of Last Inhalant Use

Frequency of Inhalant Use

Average Inhalant Use Amount

Alcohol Use

Date of Last Alcohol Use

Frequency of Alcohol Use

Average Alcohol Use Amount

Type of Alcohol Used

Beer

Wine

Liquor

Opiate Use

Date of Last Opiate Use

Frequency of Opiate Use

Average Opiate Use Amount

Synthetics Use

(e.g., Bath Salts, Ecstasy/MDMA)

Date of Last Synthetics Use

Frequency of Synthetics Use

Average Synthetics Use Amount

OTC Medication Use

(e.g., Cold/Cough Medication)

Date of Last OTC Medication Use

Frequency of OTC Medication Use

Average OTC Medication Use Amount

Specify OTC Medications Used

Nicotine Use

Date of Last Nicotine Use

Frequency of Nicotine Use

Average Nicotine Use Amount

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