Collaborative Healthcare
716 Old Cherokee Rd
Lexington, SC 29072
P: (803) 359-2273
F: (803) 359-3497

Patient Intake Form

Welcome to our online Patient Intake Form. The information you fill in will be sent directly to our office, speed up your office visit, and will help us to better serve your healthcare needs. Please take a moment to completely fill out this form, and upon completion of all form categories click the [Submit] button at the bottom of this form.

For your protection and security; Navigating away from this form before clicking the [Submit] button will dismiss all completed form fields. Successful submission will redirect you to a confirmation page.

Patient Information


Personal Information
Contact Information
Feet Inches
   
 

(We will NOT share your email with any third party. We will only use your email to contact you in relation to your care with our practice.)

   

Complaint Information


If you have more than one complaint, address your primary complaint in your responses to the questions in this section and select Yes to indicate that you have an additional complaint. The form will populate a secondary question section for you to address your additional complaint. You may address up to four complaints.

What is the purpose of your visit?
What is the reason for this visit?
Date of scheduled appointment
When did this condition begin?
How long have you had this condition?
What caused this condition?
Where is the discomfort?

Select only one area of discomfort for your chief complaint. Add additional areas of discomfort as additional complaints by selecting Yes in response to Do you have an additional complaint? at the bottom of this section.

Head

Neck

Back


Trunk

Upper Extremity






Lower Extremity





Does the discomfort radiate/travel?
Describe the quality of the discomfort. Choose all that apply.
Describe the onset of the discomfort. Choose only one.
Describe the intensity of the discomfort. Choose only one.
Rate the severity of your discomfort on a scale of 1-10 where 1 is the least severe and 10 is the most severe.
Least severe <----------------------------> Most severe
How often do you feel this discomfort? Choose only one.
How has this complaint changed since the onset?
What activity is most significantly affected by this discomfort?
What aggravates this condition? Choose all that apply.
What improves this condition? Choose all that apply.
What treatment have you received for this condition up to now?
Were any diagnostic tests performed to assess this condition (including X-rays, MRIs, etc.)?
Have you ever had any previous episodes of this condition?
In what ways does this condition affect your life and your ability to function? Choose all that apply.
Do you have an additional complaint?

Review of Systems


Musculoskeletal

Neurological

Head, Eyes, Ears, Nose and Throat

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

Endocrine

Dermatological and Bleeding

Past, Family and Social History


List your (or the patient's) past surgical history. Choose all that apply and indicate the year in which the surgeries were performed.
Describe any past illnesses or conditions the doctor should be aware of and the age at which the illness(es) reportedly occurred. Respond respectively to each illness listed. If personal health history is good, select "No past illnesses (including diabetes, cancer, hypertension and progressive neurological diseases)"





List any past history of accidents or trauma. Choose all that apply.
Are you presently taking any medication?
List your (or the patient's) family health history. Choose all that apply to blood relatives only.
What are your (or are the patient's) current work habits? Choose all that apply.



How would you describe your (or the patient's) personal social habits? Choose all that apply.




How would you describe your (or the patient's) present exercise habits? Choose all that apply.
How would you describe your (or the patient's) diet and nutritional status? Choose all that apply.

For Men Only


COMPLETE THIS SECTION ONLY IF YOU ARE (OR THE PATIENT IS) A MAN OVER 16 YEARS OF AGE.
Do you have pain or lump in scrotum or testicles?
Do you have impaired libido (sex drive)?
Do you have discharge from your penis?
Do you have prostate problems?
Estimate the date of your most recent prostate exam:
Approximate Date:   
Estimate the date of your most recent PSA (Prostate-Specific Antigen) test:
Approximate Date:   
What was your PSA (Prostate-Specific Antigen) level on your latest test?

Draw Your Symptoms


Click on a crayon and draw on the body above to indicate your symptoms
Ache / Dull Sharp / Stabbing Numb / Tingling Pins & Needles Burning Throbbing Cramping Radiating Other Pains eraser eraser clear

Employment Information


Insurance & Payment for Care


Primary Insurance
Secondary Insurance

If an auto accident, please provide:

Personal Health History


Family/Primary Physician

Separate details with "," comma as shown above.



Separate details with "," comma as shown above.

Separate details with "," comma as shown above.

Social History & Life Choices:


 

For Women Only

COMPLETE THIS SECTION ONLY IF YOU ARE (OR THE PATIENT IS) A WOMAN OVER 16 YEARS OF AGE.

Electronic Health Record (EHR) Information


Preferred Language: Ethnicity:
Race:
Smoking Status: Smoking Start Date:
Type of Tobacco:
Have you tried to quit? How much tobacco do you use?
How long have you used tobacco?
Current Medications And Dosage:
Medication Name Dosage
Medication Allergies:
Medication Name Reaction Date Discovered

Authorization

Informed Consent to Care A patient coming to the doctor gives him/her permission and authority to care for them in accordance with appropriate tests, diagnosis, and analysis. The clinical procedures performed are usually beneficial and seldom cause any problem. In rare cases, underlying physical defects, deformities or pathologies may render the patient susceptible for injury. The doctor, of course, will not provide specific healthcare, if he/she is aware that such care may be contraindicated. It is the responsibility of the patient to make it known or to learn through health care procedures from whatever he/she is suffering from: latent pathological defects, illnesses, or deformities, which would otherwise not come to the attention of the physician. I agree to settle any claim or dispute I may make against or with any of these persons or entities, whether related to the prescribed care or otherwise, will be resolved by binding arbitration under the current malpractice terms which can be obtained by written request. PHYSICIAN NETWORK AUTHORIZATION/CONSENT FORM GENERAL AUTHORIZATION FOR TREATMENT/CONTACT I authorize physicians, nurse practitioners, and/or physician assistants of Collaborative Healthcare who may attend me, their assistants, including those employed by Collaborative Healthcare to provide the medical care, test, procedures, drugs, blood and blood products, services, and supplies considered advisable by my provider. These services may include pathology, radiology, emergency services and other special services ordered by my provider. In consenting to treatment, I have not relied on any statements as to results. I further authorize my provider to examine, use, store, and/or dispose of in any manner (except for organ donation and/or transplantation) any tissue, fluids or parts removed from my body. In the event that any personnel assisting in the provision of care and treatment suffer inadvertent exposure to any of my blood and/or other bodily substances that are capable of transmitting disease and I am unable to consult in timely with my physician prior to testing, I consent to limited testing to determine presence, if any, of antibodies to hepatitis A, B, and C and HIV. I authorize Collaborative Healthcare to contact me on any phone number provided by me for the purposes of conducting business with me or contacting me concerning my account. I consent to the use of automated dialers for that purpose. This authorization form permits: Collaborative Healthcare – 716 Old Cherokee Rd – Lexington, SC 29072 to use or disclose protected health information listed in the description section below for the above patient. Entity or person to receive the information: The Patient Description of information to be used or disclosed: Unencrypted email / text communications to give you information about treatment alternatives, or other health related benefits, events or services. If you do not wish to receive the information about treatment alternatives, other health related benefits, events or services, you may notify our office in writing (Emails/text NOT accepted) and you will receive no further information. Purpose of use or disclosure: To inform patients of healthcare options, surveys or events. There will be NO remuneration or financial payment made to our facility for making these communications. Expiration date or event: This authorization shall be enforced until revoked by the patient by notifying our office in writing (Emails/text NOT accepted). Rights of the Patient: I understand that I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing. I understand that I have the right to revoke this authorization at any time by sending a written notification to the address listed at the top of this form I understand that a revocation is not effective in cases where the information has already been used or disclosed but will be effective going forward. I understand that information used or disclosed as a result of this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law. RELEASE AND ASSIGNMENT OF BENEFITS I understand that payment is due at the time service is rendered. I hereby authorize the release of any medical information to (1) an insurance company through which I claim benefits and (2) any physician involved in my medical care. I realize the authorization allows Collaborative Healthcare to release any information to any of my insurers or physicians. I authorize and direct my insurers to pay directly to Collaborative Healthcare and/or its physicians/providers any and all benefits up to the amount of my bill pertaining to all charges incurred. I assign to Collaborative Healthcare, including its affiliates, any and all benefits or proceeds, of any type whatsoever, to which I am entitled, with respect to the health care service(s) I receive, including but not limited to, the proceeds of any liability settlement or judgment being paid by or on behalf of a third-party and any benefits due from any third-party insurance policy. I direct that all such benefits be paid directly to Collaborative Healthcare and/or its affiliates, including its physician/providers, and applied to my account(s) until the account(s) is paid in full. I understand that I am personally responsible for any remaining fees. I hereby agree to pay all costs and reasonable attorney fees in the even this account is turned over to an attorney and/or collection agency for collection. ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I hereby acknowledge that I have received the Notice of Privacy Practices for Collaborative Healthcare.I agree that a photo static copy of this agreement shall serve as the original.

Name of the Insured:
(Please Print)
_____________________________________________    
Patient's/Guardian's signature:
_____________________________________________
Date:
__________

Signature


Finalizing Form


  1. Submit Form!