Electronic Health Records Intake Form - Rizzo & Wiegering Chiropractic printable pdf download

Electronic Health Records Intake Form - Rizzo & Wiegering Chiropractic

Rizzo & Wiegering Chiropractic

502 Logan Blvd.

Altoona, PA 16602

814-944-3536 Phone

Electronic Health Records Intake Form

In compliance with requirements for the government EHR incentive program

First Name:_________________________

Last Name:_________________________

Email address: _________________@_________________

Can we send you text reminders for appointments, etc? Y / N ?

Cell #: _______________________

DOB: __/__/____

Gender (Circle one): Male / Female

Preferred Language: __________________

Smoking Status (Circle one): Every Day Smoker / Occasional Smoker / Former Smoker / Never Smoked

CMS requires providers to report both race and ethnicity

Race (Circle one): American Indian or Alaska Native / Asian / Black or African American / White (Caucasian)

Native Hawaiian or Pacific Islander / Other / I Decline to Answer

Ethnicity (Circle one): Hispanic or Latino / Not Hispanic or Latino / I Decline to Answer

Are you currently taking any medications? (Please include regularly used over the counter medications)

Medication Name

Dosage and Frequency (i.e. 5mg once a day, etc.)

Do you have any medication allergies?

Medication Name

Reaction

Onset Date

Additional Comments

□

I choose to decline receipt of my clinical summary after every visit (These summaries are often blank as a

result of the nature and frequency of chiropractic care.)

Patient Signature: _____________________________________________

Date:________________

For office use only

Height: _________

Weight:____________ Blood Pressure:______ /______

Electronic Health Records Intake Form - Rizzo & Wiegering Chiropractic